2c:I[856015,["/_next/static/immutable/chunks/1xzisbplk9czp.js","/_next/static/immutable/chunks/3j2i1faptc_-9.js","/_next/static/immutable/chunks/1bqb83_yclja0.js","/_next/static/immutable/chunks/1on664om2hmh1.js","/_next/static/immutable/chunks/30t4sjq-27eg7.js","/_next/static/immutable/chunks/08tq8rmv423j5.js","/_next/static/immutable/chunks/32zk736rs0hqw.js","/_next/static/immutable/chunks/0lbgs964whs_0.js","/_next/static/immutable/chunks/1a_hqhrsle_n_.js","/_next/static/immutable/chunks/0hcnvyarhzl7i.js"],"default"] 2d:T6f7c,

Summary Table

Domain	Detail
Risk Factors	Males aged 20 to 50 (acute bacterial); history of UTIs, urinary catheterization, recent urologic procedure, unprotected intercourse, BPH, immunosuppression
Etiology	Acute/Chronic Bacterial: Gram-negative rods, most commonly E. coli (~80%). Less common: Klebsiella, Proteus, Pseudomonas, Enterococcus. In younger sexually active men: Chlamydia trachomatis, Neisseria gonorrhoeae. Chronic Pelvic Pain Syndrome (CPPS): Non-bacterial, multifactorial
Patient Presentation	Acute: Fever, chills, dysuria, perineal/pelvic pain, urinary frequency/urgency, obstructive voiding symptoms. Chronic bacterial: Recurrent UTIs with pelvic discomfort between episodes. CPPS: Chronic pelvic/perineal pain for 3+ months without documented infection
Classic Physical Exam	Acute: DRE reveals a boggy, exquisitely tender, warm, swollen prostate. Chronic: Prostate may be normal or mildly tender on DRE
Key Diagnostic Results	Urinalysis with pyuria and bacteriuria; positive urine culture (E. coli); elevated PSA (non-diagnostic, can be a trap); leukocytosis in acute form; 4-glass Meares-Stamey test for chronic classification
Management	Acute: Fluoroquinolone (ciprofloxacin or levofloxacin) or TMP-SMX for 4 to 6 weeks. If systemically ill: IV antibiotics. Chronic bacterial: Fluoroquinolone for 4 to 6 weeks. CPPS: Alpha-blockers, NSAIDs, trial of antibiotics
Keywords	"Boggy, tender prostate"; "young man with fever, dysuria, and perineal pain"; "recurrent UTIs in a male"; "do NOT massage the prostate"; "chronic pelvic pain with negative cultures"

1. Pathophysiology

Prostatitis refers to inflammation of the prostate gland, which can be infectious or non-infectious in origin. Understanding the anatomy is the foundation: the prostate surrounds the prostatic urethra just below the bladder neck. This anatomic position explains why prostatic inflammation produces both irritative voiding symptoms (dysuria, frequency, urgency) and obstructive symptoms (hesitancy, weak stream, incomplete emptying).

In acute bacterial prostatitis, the most common mechanism is ascending urethral infection by gram-negative enteric organisms, with E. coli accounting for roughly 80% of cases. Bacteria colonize the prostatic ducts, triggering an intense neutrophilic inflammatory response. The resulting edema and glandular swelling produce the characteristic boggy, tender prostate on digital rectal exam. The intense inflammation also explains the systemic signs: high fever, chills, and leukocytosis. Because the inflamed prostate compresses the urethra, patients may develop acute urinary retention, which is a commonly tested complication.

In chronic bacterial prostatitis, the same organisms persist within the prostate despite prior antibiotic courses. The prostate gland contains prostatic calculi and biofilm-forming niches that shield bacteria from both antibiotics and host immune defenses. This is why patients experience recurrent UTIs with the same organism separated by asymptomatic intervals. The prostate essentially serves as a reservoir for reinfection of the urinary tract.

Chronic pelvic pain syndrome (CPPS), which is the most common form of prostatitis encountered clinically, has a poorly understood pathophysiology. Proposed mechanisms include neuromuscular dysfunction of the pelvic floor, autoimmune inflammation, and neuropathic pain sensitization. The hallmark is chronic pelvic/perineal pain lasting more than 3 months with no identifiable bacterial pathogen on culture. This distinction from chronic bacterial prostatitis is a frequent testing point.

2. Classification and Clinical Manifestation

NIH Classification System

Category	Name	Infectious?	Key Clinical Features	Exam Relevance
I	Acute Bacterial Prostatitis	Yes	Acute onset fever, chills, severe dysuria, perineal pain, boggy/tender prostate on DRE. May present with sepsis or urinary retention	Most commonly tested. Recognize the acutely ill young male with a tender prostate
II	Chronic Bacterial Prostatitis	Yes	Recurrent UTIs (same organism), mild pelvic discomfort between episodes, symptoms for >3 months	Tested as "recurrent UTIs in a male"
IIIa	CPPS, Inflammatory	No	Chronic pelvic/perineal pain >3 months, WBCs in prostatic secretions but negative cultures	Distinguish from Category II by culture results
IIIb	CPPS, Non-inflammatory	No	Chronic pelvic/perineal pain >3 months, no WBCs in prostatic secretions, negative cultures	Most common form overall; diagnosis of exclusion
IV	Asymptomatic Inflammatory Prostatitis	No	No symptoms. Incidental finding of WBCs on biopsy or semen analysis	Not clinically managed. Found incidentally during infertility workup or prostate biopsy

Clinical features by System

System	Acute Bacterial (Cat I)	Chronic Bacterial (Cat II)	CPPS (Cat III)
Constitutional	High fever, rigors, malaise	Usually afebrile	Afebrile
Urinary	Severe dysuria, frequency, urgency, retention	Recurrent dysuria, frequency	Variable irritative symptoms
Pain	Intense perineal, suprapubic, low back pain	Dull perineal/pelvic ache	Chronic perineal, suprapubic, penile tip, or ejaculatory pain
Sexual	Painful ejaculation	Painful ejaculation, hematospermia	Painful ejaculation, erectile dysfunction
DRE	Boggy, hot, exquisitely tender	Normal to mildly tender	Usually normal

3. Diagnostic Workup

Test	Role	Key Findings	When to Use
Urinalysis + Urine Culture	Best Initial Test (Acute)	Pyuria, bacteriuria; positive culture (usually E. coli)	All suspected cases
Blood Cultures	Evaluate for bacteremia/sepsis	Positive in ~30% of acute cases	Acute bacterial with systemic toxicity
CBC	Supporting evidence	Leukocytosis with left shift	Acute bacterial
PSA	Not diagnostic; can mislead	Elevated in acute prostatitis; normalizes after treatment	Do NOT use PSA to screen for cancer during active prostatitis
4-Glass Meares-Stamey Test	Gold Standard for classification	Compares bacterial counts and WBCs across 4 specimens to localize infection to the prostate	Chronic bacterial vs. CPPS. Never perform during acute prostatitis
2-Glass (PPMT) Test	Simplified alternative to 4-glass	Pre-massage and post-massage urine specimens	Chronic evaluation when 4-glass test is impractical
Transrectal Ultrasound (TRUS)	Evaluate complications	Prostatic abscess (hypoechoic collection)	Acute prostatitis failing to improve after 48 to 72 hours of appropriate antibiotics
CT Pelvis	Alternative abscess evaluation	Ring-enhancing prostatic collection	When abscess is suspected
Cystoscopy	Rule out structural pathology	Urethral stricture, bladder pathology	Chronic/recurrent cases unresponsive to therapy

For Acute Bacterial Prostatitis (Category I)

The diagnosis is primarily clinical. A young to middle-aged male presenting with fever, dysuria, perineal pain, and a boggy/tender prostate on DRE has acute bacterial prostatitis until proven otherwise. The best initial test is a urinalysis with urine culture obtained by midstream clean-catch (not catheterization if avoidable, as catheter passage through an inflamed prostate is painful and risks bacteremia). Expect pyuria, bacteriuria, and a positive culture growing a gram-negative rod.

Order blood cultures and a CBC if the patient appears septic or systemically toxic. Blood cultures are positive in approximately 30% of acute cases.

A critical rule: Do NOT perform prostatic massage in acute bacterial prostatitis. Vigorous manipulation of an acutely infected, inflamed gland risks bacteremia and sepsis. This is one of the most tested facts on this topic.

PSA will often be elevated during acute prostatitis, but this is a reactive elevation and must not be interpreted as evidence of prostate cancer. PSA should be rechecked after resolution of infection (typically 6 to 8 weeks later) to obtain a meaningful baseline.

If a patient with acute bacterial prostatitis does not improve after 48 to 72 hours of appropriate IV antibiotics, suspect a prostatic abscess and obtain imaging, typically transrectal ultrasound or CT pelvis with contrast.

For Chronic Bacterial Prostatitis (Category II) and CPPS (Category III)

The gold standard for distinguishing chronic bacterial prostatitis from CPPS is the Meares-Stamey 4-glass test. This involves sequential collection of:

VB1 (voided bladder 1): First 10 mL of urine (urethral specimen)
VB2 (voided bladder 2): Midstream urine (bladder specimen)
EPS (expressed prostatic secretions): Obtained by prostatic massage
VB3 (voided bladder 3): First 10 mL after massage (prostatic specimen)

If the bacterial count in EPS or VB3 is at least 10-fold higher than in VB1 and VB2, the infection is localized to the prostate, confirming Category II (chronic bacterial prostatitis). If WBCs are present in EPS/VB3 but cultures are negative, the diagnosis is Category IIIa (inflammatory CPPS). If neither WBCs nor bacteria are found, the diagnosis is Category IIIb (non-inflammatory CPPS).

A simplified 2-glass pre- and post-massage test (PPMT) compares a pre-massage midstream urine to a post-massage urine and is considered an acceptable alternative in clinical practice.

4. Management and Treatment

Category	First-Line Agent	Route	Duration	Alternatives/Adjuncts
I (Acute), Outpatient	Ciprofloxacin 500 mg PO BID or Levofloxacin 500 mg PO daily	Oral	4 to 6 weeks total	TMP-SMX 160/800 mg PO BID if fluoroquinolone-resistant
I (Acute), Septic/Hospitalized	Ampicillin + Gentamicin IV or Ceftriaxone 1 to 2 g IV daily or Fluoroquinolone IV	Intravenous, then step down to oral	IV until afebrile 24 to 48 hours, then oral to complete 4 to 6 weeks	Add aminoglycoside for Pseudomonas coverage if risk factors present
II (Chronic Bacterial)	Ciprofloxacin 500 mg PO BID or Levofloxacin 500 mg PO daily	Oral	4 to 6 weeks (some guidelines allow up to 12 weeks for refractory cases)	TMP-SMX for 1 to 3 months if fluoroquinolone-intolerant
IIIa/IIIb (CPPS)	Alpha-blocker (tamsulosin 0.4 mg daily) + NSAIDs	Oral	6 to 12 weeks trial	Trial of doxycycline or fluoroquinolone for 4 to 6 weeks; pelvic floor physical therapy; tricyclic antidepressants for neuropathic pain
IV (Asymptomatic)	No treatment required	N/A	N/A	Found incidentally; observe
Prostatic Abscess	IV antibiotics + drainage (transrectal or transurethral)	IV then oral	Guided by clinical response	Drainage is required if abscess >2 cm or fails to resolve with antibiotics alone

Acute Bacterial Prostatitis

The cornerstone of treatment is prolonged antibiotic therapy. Fluoroquinolones are preferred because they achieve excellent penetration into prostatic tissue, unlike many beta-lactams that penetrate poorly. The standard outpatient regimen is ciprofloxacin 500 mg PO twice daily or levofloxacin 500 mg PO once daily for a total of 4 to 6 weeks. The extended duration is necessary because the prostate's ductal anatomy creates sanctuaries where bacteria can survive shorter courses, and undertreating risks conversion to chronic bacterial prostatitis (Category II).

For the patient who is systemically ill, septic, or unable to tolerate oral medications, start with intravenous antibiotics. A common empiric IV regimen includes ampicillin plus gentamicin for enterococcal coverage, or a third-generation cephalosporin (ceftriaxone) with or without an aminoglycoside. Transition to oral fluoroquinolone once the patient is afebrile for 24 to 48 hours and clinically improving, then complete 4 to 6 weeks total.

If the patient develops acute urinary retention, manage with suprapubic catheterization rather than transurethral catheterization. Passing a Foley catheter through an acutely inflamed prostate is painful, technically difficult, and risks worsening infection or causing bacteremia.

Chronic Bacterial Prostatitis

The same fluoroquinolone regimens are used for the same duration (4 to 6 weeks minimum). Some patients with refractory or relapsing disease may require up to 12 weeks of therapy. Alpha-blockers (tamsulosin) can be added as adjunctive therapy to relieve obstructive symptoms.

For patients with recurrent episodes despite adequate antibiotic courses, consider low-dose suppressive antibiotic therapy (e.g., TMP-SMX or nitrofurantoin at bedtime) to prevent symptomatic UTI recurrences. In rare refractory cases with documented prostatic calculi serving as a nidus, transurethral resection of the prostate (TURP) has been used, although this is not a first-line approach.

CPPS (Category III)

Management is multimodal and empiric because no single therapy is consistently effective. The initial approach combines:

Alpha-blocker (tamsulosin 0.4 mg daily) for a minimum 6-week trial to relax prostatic smooth muscle and bladder neck
NSAIDs for anti-inflammatory and analgesic effect
A 4 to 6 week empiric trial of antibiotics (doxycycline or a fluoroquinolone) is reasonable in treatment-naive patients, as some patients with CPPS may harbor fastidious organisms not detected on standard culture

If initial therapy fails, consider pelvic floor physical therapy (increasingly recognized as beneficial), tricyclic antidepressants (amitriptyline) for neuropathic pain modulation, or referral to a pain specialist.

5. Differential Diagnosis and Distractors

Differential	Why It Looks Similar	Key Discriminator
Benign Prostatic Hyperplasia (BPH)	Obstructive voiding symptoms (hesitancy, weak stream, frequency, nocturia) overlap with prostatitis	BPH presents in older men (>50), is painless, afebrile, and the prostate is symmetrically enlarged but non-tender on DRE. No pyuria or positive urine culture
Urinary Tract Infection (Cystitis)	Dysuria, frequency, urgency, and pyuria overlap directly	Simple cystitis has no systemic symptoms (no fever, no chills), no perineal/pelvic pain, and a normal DRE. UTI in a young male should raise suspicion for prostatitis
Epididymitis	Fever, dysuria, and scrotal/perineal pain in a young male	Pain and swelling localized to the epididymis/scrotum rather than the perineum. Positive Prehn sign (relief with scrotal elevation). Prostate is normal on DRE
Prostate Cancer	Elevated PSA, abnormal DRE	Prostate cancer is typically painless, found in older men, and DRE reveals a hard, irregular nodule rather than a diffusely boggy, tender gland. No fever, no pyuria
Urethritis (STI)	Dysuria and urethral discharge in a sexually active young male	Urethral discharge is the dominant finding. No fever, no perineal pain, normal DRE. Urethral swab positive for N. gonorrhoeae or C. trachomatis
Prostatic Abscess	Persistent fever, perineal pain, and tender prostate despite antibiotics for acute prostatitis	Suspect when acute prostatitis fails to improve after 48 to 72 hours of appropriate IV antibiotics. Diagnosed by TRUS or CT showing a fluid collection. Requires drainage
Bladder Cancer	Irritative voiding symptoms, hematuria	Painless gross hematuria in an older patient with smoking history. Cystoscopy and urine cytology confirm
Chronic Pelvic Pain (non-urologic)	Chronic pelvic/perineal pain overlapping with CPPS	Consider musculoskeletal, GI (irritable bowel), or neurologic etiologies. Urologic workup is normal. Absence of any urinary symptoms or DRE abnormality points away from prostatitis

6. Traps and High-Yield Pearls

The single most tested trap on prostatitis is the contraindication to prostatic massage in acute bacterial prostatitis. A vignette will describe an acutely febrile young man with a tender prostate and then ask for the "next best step." Students who select "obtain expressed prostatic secretions" or "perform the 4-glass test" will get this wrong. The Meares-Stamey test is reserved for chronic prostatitis classification, never for an acute presentation where massage risks bacteremia and sepsis.

The second common trap involves PSA interpretation. A vignette may present a patient recovering from acute prostatitis whose PSA is found to be elevated. The question tests whether you know to defer PSA-based cancer screening until 6 to 8 weeks after the infection resolves, because inflammation falsely elevates PSA. Ordering a prostate biopsy during or immediately after prostatitis is the wrong answer.

A third testing angle is the prolonged antibiotic duration. Students accustomed to treating simple UTIs for 3 to 7 days will undertreat prostatitis. The prostate's poor antibiotic penetration (relative to the bladder mucosa) demands 4 to 6 weeks of therapy. Vignettes that present a patient whose prostatitis symptoms recur after a short antibiotic course are testing whether you recognize inadequate treatment duration as the cause of relapse.

Finally, know the management of urinary retention complicating acute prostatitis. The answer is suprapubic catheterization, not a transurethral Foley. This comes up reliably because it is counterintuitive to students who default to Foley catheterization for retention in other settings.

The core competency being tested across all prostatitis questions is the ability to classify the type of prostatitis based on the clinical presentation, then match the correct diagnostic approach and treatment duration to that category, while avoiding procedural complications (massage in acute disease, Foley in retention, premature biopsy after elevated PSA).

1d:["$","$L2c",null,{"article":{"id":"67db80e6-2640-456b-a6ee-d15f66d4155e","title":"Prostatitis","content":"$2d","category":"Uronefrologi","created_at":"2026-09-05T11:57:27.275779+00:00","status":"published","subcategory":null},"questionCount":0,"sections":[{"id":"section-pathophysiology","num":"01","title":"Pathophysiology"},{"id":"section-classification-and-clinical-manifestation","num":"02","title":"Classification and Clinical Manifestation"},{"id":"section-diagnostic-workup","num":"03","title":"Diagnostic Workup"},{"id":"section-management-and-treatment","num":"04","title":"Management and Treatment"},{"id":"section-differential-diagnosis-and-distractors","num":"05","title":"Differential Diagnosis and Distractors"},{"id":"section-traps-and-high-yield-pearls","num":"06","title":"Traps and High-Yield Pearls"}],"hasSummaryTable":true}]