“Are we missing acute bacterial prostatitis?”
Author: Charlotte Davies
Codes: C3AP5, C3AP9
There are four main types of prostatitis. Although not the most common, acute bacterial prostatitis is the most likely to present to the emergency department.
Acute Bacterial Prostatitis
Acute prostatitis is a common disease amongst men over 50 years of age, especially those who are immunocompromised, like in diabetes or HIV/AIDs.
It often presents with frequency, urgency and dysuria. In women, we might attribute these symptoms to a UTI, but UTI is rare in men without anatomical abnormalities, until the prostate starts to get bigger, increasing the frequency again. We should consider doing a scrotal, genital and rectal examination in any man diagnosed with a UTI, to check there isn’t something else.
There might be obstructive voiding symptoms in >80% of patients. 38% of people get perineal discomfort which may present as back or rectal pain.
Some people get systemic features. Can get fever in 60% – 86%, maybe with rigors, malaise and myalgias.
Look for signs of urinary retention. If in retention, let the most experienced person present attempt a urethral catheter. If that isn’t successful, don’t keep trying – contact urology for early consideration of a suprapubic catheter.
Classically described as exquisitely painful and boggy, actually you only get a painful prostate in 68%. Pain or symptom reproducability is probably the most important symptom.
- Urinalysis – send sample off for culture.
- Leucocytes and nitrites have a great positive predictive value, but not a great negative predictive value.
- Blood cultures – positive in 8 – 21% of cases
- CRP raised in most cases
- If there’s microhaematuria on the dip, make sure it gets repeated as it might be a sign of cancer.
- PSA – not clear role, but has a high negative predictive value
- PR without prostatic massage makes minimal difference to the serum PSA value and generally does not cause a clinically significant increase in PSA levels.
So how do you tell if someone has prostatitis, or just a UTI? And like many things, there’s no real answer. If they’ve got a painful or boggy mass on examination, then the answer is easy! If they haven’t…could it still be prostatitis? Generally, yes it could be. The patients are normally significantly unwell – the risk of bacteraemia is increased in severe UTIs like pyelonephritis and prostatitis. I think it’s reasonable if you have a really really sick ?urinary sepsis, to assume prostatitis until proven otherwise.
- Broad spectrum (cephalosporin) plus gentamycin if patient is systemically unwell.
- If oral antibiotics are appropriate, use
- Ciprofloxacin 500mg BD for 28 days or
- Ofloxacin 200mg BD for 28 days
- If patient is allergic to quinolones, consider trimethoprim (200mg BD for 28days) as an alternative. It needs to be for a long time because the prostate has quite a poor blood supply.
- Laxatives – if defacation uncomfortable
- It is possible to add on an alpha blocker such as tamsulosin which has been proven as an beneficial adjunct for symptom relief.
If fails to respond, arrange trans-rectal USS or CT of the prostate to R/U prostate abscess. Prostatic abscesses are relatively uncommon due to clinical practice due antibiotic therapy. Like prostatitis, common presenting features are dysuria, fever, suprapubic pain +/- urinary retention. Urine examination usually reveals pus cells. The organisms usually involved include:
- Escherichia coli
- Staphylococcus spp
- Gonococcus spp: rare
- RCEM Learning – Acute Urinary Retention
- WikiEM – Prostatitis
- BMJ Learning
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