Bacterial Prostatitis

Bacterial prostatitis is an infection of the prostate gland caused by bacteria that can appear suddenly or develop gradually over time, causing pain, urinary problems, and sometimes flu-like symptoms that require proper medical treatment.

Table of contents

• What is bacterial prostatitis?
• The prostate gland
• Types of bacterial prostatitis
• What causes bacterial prostatitis?
• Risk factors
• Symptoms
• How is it diagnosed?
• Treatment
• Prevention

What is bacterial prostatitis?

Bacterial prostatitis is a condition where the prostate gland becomes infected and swollen due to bacteria. This infection can cause pain in the lower body, problems with urination, and in some cases, symptoms similar to the flu. Bacterial prostatitis is less common than other types of prostate problems, but it requires prompt medical attention and treatment with antibiotics^[1].

Although more than 2 million men visit healthcare providers for prostatitis symptoms each year, bacterial causes account for less than 10% of all prostatitis cases. However, when bacteria do cause the infection, proper diagnosis and treatment are essential^[1][12].

The prostate gland

• Prostate gland
• Bladder
• Urethra
• Rectum

The prostate is a small gland, about the size of a walnut, that sits below the bladder and in front of the rectum. The urethra (the tube that carries urine and semen out of the body) runs through the center of the prostate. The main job of the prostate is to make fluid that becomes part of semen, which is important for male fertility^[1][2].

When the prostate becomes infected or inflamed, the tissue in and around the gland becomes swollen, tender, and irritated. This swelling can affect the urethra and make it difficult or painful to urinate^[1].

Types of bacterial prostatitis

There are two main types of bacterial prostatitis, each with different characteristics and treatment approaches^[1][2].

Acute bacterial prostatitis is a sudden bacterial infection of the prostate. This type comes on quickly and can be quite serious. Men with acute bacterial prostatitis often have fever and chills along with severe urinary symptoms. They may experience painful and frequent urination or have trouble urinating at all. Acute bacterial prostatitis is a medical emergency that requires immediate treatment with antibiotics^[1][5].

Chronic bacterial prostatitis is also caused by bacteria, but the symptoms develop more gradually and can last for three months or longer. Unlike the acute form, chronic bacterial prostatitis usually does not cause fever and chills. However, men still experience pain when urinating and difficulty with urination. This type can take longer to treat and may come back even after treatment^[1][3].

It is estimated that acute bacterial prostatitis makes up approximately 10% of all prostatitis cases. After an episode of acute bacterial prostatitis, about 5% of patients may develop chronic bacterial prostatitis^[5][6].

What causes bacterial prostatitis?

Bacterial prostatitis is caused by bacteria that infect the prostate gland. The most common bacterium responsible is Escherichia coli (E. coli), which normally lives in the intestines. E. coli causes approximately 50% to 90% of bacterial prostatitis cases^[4][5].

Other bacteria that can cause prostatitis include Pseudomonas aeruginosa, Klebsiella, Enterococcus, Enterobacter, Proteus, and Serratia species. Sometimes, bacteria from sexually transmitted infections such as Neisseria gonorrhoeae (which causes gonorrhea), Chlamydia trachomatis, or Ureaplasma urealyticum can also cause bacterial prostatitis^[4][5].

Most cases of bacterial prostatitis are caused by bacteria ascending through the urethra or by intraprostatic reflux (when infected urine flows backward into the prostate). Occasionally, bacteria can spread to the prostate directly from the rectum, through the lymphatic system, or through the bloodstream during a severe bacterial infection elsewhere in the body^[5][7].

People with weakened immune systems are at higher risk of developing bacterial prostatitis from unusual organisms, including certain species of Salmonella, Mycobacterium, and Staphylococcus. In these patients, fungal and viral causes should also be considered^[4].

Risk factors

Several conditions and circumstances can increase a man’s risk of developing bacterial prostatitis^[5][7]:

• Having an enlarged prostate (benign prostatic hypertrophy), which can block urine flow and make bacterial growth easier
• Medical procedures involving the prostate or urethra, such as urinary catheterization, cystoscopy, transrectal prostate biopsy, or transurethral surgery
• Urinary tract infections or other infections of the genitourinary system, including epididymitis, orchitis, or urethritis
• Sexually transmitted diseases or having multiple sexual partners
• Being immunocompromised (having a weakened immune system)
• Having a urethral stricture (narrowing of the urethra)
• Phimosis (foreskin that cannot be pulled back)
• Injury to the area between the scrotum and anus (the perineum)

Bacterial prostatitis affects men of different ages, with the highest rates occurring in men between 20 to 40 years old and in men older than 70 years. Men over 50 with an enlarged prostate have a higher risk because the prostate gland may become blocked, making it easier for bacteria to grow^[3][5].

Most acute bacterial prostatitis infections are acquired in the community, but some occur in hospitals or healthcare facilities. Community-acquired infections are three times more common than hospital-acquired infections^[5][7].

Symptoms

The symptoms of bacterial prostatitis vary depending on whether it is acute or chronic. Both types can cause significant discomfort and affect quality of life^[1][2].

Common symptoms of both acute and chronic bacterial prostatitis include^[1][2][3]:

• Pain or burning feeling when urinating (dysuria)
• Difficulty starting to urinate or keeping the stream going
• A urine stream that stops and starts
• Frequent urge to urinate, especially at night (nocturia)
• Urgent need to urinate
• Blood in the urine (hematuria)
• Blood in the semen (hematospermia)
• Cloudy or foul-smelling urine
• Weak urine stream
• Pain in the lower abdomen, groin, lower back, or area between the genitals and anus
• Pain in the testicles
• Pain during sexual intercourse (dyspareunia)
• Painful ejaculation
• Difficulty achieving or maintaining an erection (erectile dysfunction)
• Pain with bowel movements

Acute bacterial prostatitis can also cause severe symptoms that develop suddenly, including^[1][3][5]:

• High fever
• Chills and shaking
• Body aches
• Nausea and vomiting
• Feeling generally unwell (malaise)
• Flushing of the skin
• Lower stomach tenderness

In severe cases of acute bacterial prostatitis, the swollen prostate can completely block the flow of urine from the bladder. This is a medical emergency that requires immediate treatment^[7].

Chronic bacterial prostatitis symptoms are similar to those of acute prostatitis but are usually less severe. They often begin more slowly and can come and go over a period of months. Some people have no symptoms between episodes of prostatitis^[3][6].

How is it diagnosed?

Healthcare providers diagnose bacterial prostatitis mainly based on medical history, symptoms, and physical examination. Several tests may be performed to confirm the diagnosis and identify the specific bacteria causing the infection^[5][7].

During a physical examination, the doctor may perform a digital rectal exam (DRE). For this exam, the provider inserts a lubricated, gloved finger into the rectum to feel the prostate. In acute bacterial prostatitis, the prostate may feel swollen and tender. In chronic bacterial prostatitis, it may feel large and soft. This exam should be done very gently in acute cases to reduce the risk of spreading bacteria into the bloodstream^[3][5].

The physical exam may also reveal^[3]:

• Enlarged or tender lymph nodes in the groin
• Fluid released from the urethra
• A swollen or tender scrotum

Urine cultures are essential for diagnosing bacterial prostatitis. These tests identify which bacteria are causing the infection and help determine which antibiotics will work best. Urine samples should be obtained from all patients suspected of having bacterial prostatitis. A midstream urine sample (collected after starting urination) is typically used^[5][7].

Additional tests may include^[3][10]:

• Urinalysis: examining urine under a microscope to look for signs of infection
• Blood tests: checking for signs of infection and other problems
• Blood cultures: recommended for patients with high fever (greater than 101.1°F or 38.4°C), suspected blood infection, or weakened immune systems
• Prostatic specimen test: sometimes the doctor may gently massage the prostate during a rectal exam to release fluid from the prostate into the urethra. A urine sample collected after this massage can be tested for infection. This test is not done in acute bacterial prostatitis because it could spread bacteria into the blood

The prostate-specific antigen (PSA) blood test may show elevated levels during bacterial prostatitis. However, this test is not used to diagnose prostatitis because PSA can be elevated for other reasons, including prostate cancer. PSA levels usually return to normal after successful treatment of the infection, although this may take three to six months^[5][16].

Imaging tests are typically not needed to diagnose bacterial prostatitis. However, if fever persists for longer than 36 hours despite treatment, imaging may be done to check for complications such as a prostate abscess (a collection of pus in the prostate)^[5][7].

Treatment

The main treatment for bacterial prostatitis is antibiotics. The specific antibiotic, dose, and length of treatment depend on whether the infection is acute or chronic, how severe it is, and which bacteria are causing it^[3][10].

Treatment of acute bacterial prostatitis

Men with acute bacterial prostatitis who appear very ill, have signs of widespread infection (sepsis), cannot urinate, cannot keep down food or liquids, or have risk factors for antibiotic resistance should be hospitalized. In the hospital, they receive antibiotics through an intravenous (IV) line. Common IV antibiotics include ceftriaxone and doxycycline, ciprofloxacin, or piperacillin/tazobactam^[5][11].

Most patients with acute bacterial prostatitis can be treated at home with oral antibiotics. The typical treatment course is 2 to 6 weeks. Fluoroquinolones (such as ciprofloxacin or levofloxacin) are often used because they work well and penetrate the prostate tissue effectively. If sexually transmitted bacteria like chlamydia are suspected, a macrolide antibiotic may be used instead^[3][7][11].

It is very important to take the full course of antibiotics as prescribed, even if symptoms improve. Stopping antibiotics too early can allow the infection to return or become chronic^[3][15].

Treatment of chronic bacterial prostatitis

Chronic bacterial prostatitis requires a longer course of antibiotics, typically lasting at least 2 to 6 weeks. In some cases, treatment may need to continue for up to 12 weeks to fully clear the infection. Even after long-term treatment, the infection may not go away completely, and symptoms can return when medication is stopped. If symptoms come back after initial successful treatment, another 4- to 6-week course of antibiotics may be prescribed, possibly combined with other medications^[3][6][17].

Supportive care and additional treatments

In addition to antibiotics, several other treatments can help relieve symptoms^{[3][10][11][15]}:

• Over-the-counter pain medications such as acetaminophen, ibuprofen, or naproxen to reduce pain and fever
• Alpha-adrenergic blocking agents (alpha blockers) to relax tight muscles in the prostate and bladder neck, making urination easier
• Warm baths to help soothe pain
• Drinking plenty of fluids (unless advised otherwise by a doctor)
• Urinating often and completely
• Stool softeners or high-fiber foods to prevent constipation, since straining during bowel movements can be painful when the prostate is inflamed
• Avoiding alcohol, caffeine, and spicy or acidic foods if they make symptoms worse

If the swollen prostate blocks urination completely, a catheter (a thin tube) may need to be inserted to drain urine from the bladder. A suprapubic catheter (inserted through the abdomen) is often safer than a urethral catheter (inserted through the penis) in cases of severe blockage from acute infection^[3][11].

In rare cases where a prostate abscess develops, it may need to be drained. This can be done through the rectum, through the perineum (the area between the scrotum and anus), or through a cystoscope (a viewing instrument inserted through the urethra)^[11].

Follow-up with a healthcare provider is essential to ensure the infection has been completely treated and to provide continuity of care to prevent relapse^[11][15].

Prevention

Some cases of bacterial prostatitis can be prevented by taking precautions during medical procedures. The risk of developing bacterial prostatitis after a transrectal prostate biopsy can be reduced by taking antibiotics, such as ciprofloxacin, before the procedure^[5][7].

Other preventive measures may include^[3]:

• Practicing safe sex to reduce the risk of sexually transmitted infections
• Seeking prompt treatment for urinary tract infections
• Maintaining good hygiene
• Staying well-hydrated