Urology
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A 42 year old man presents to ED complaining of dysuria and urgency associated with fever for the past 3 weeks. He has no past medical history. He has seen his GP who has prescribed two different courses of antibiotics but his condition has not improved. What is the most likely diagnosis?
Answer:
Suspect acute prostatitis in a man who presents with signs and symptoms of:- A urinary tract infection (UTI):
- Dysuria, frequency, urgency
- Prostatitis:
- Perineal, penile, or rectal pain
- Acute urinary retention, obstructive voiding symptoms (difficulty voiding, hesitancy, straining to urinate, weak stream)
- Low back pain, pain on ejaculation
- Tender, swollen, warm prostate (on gentle rectal examination)
- Bacteraemia:
- Rigors, arthralgia, or myalgia
- Fever, tachycardia
Acute Prostatitis
Urology
Last Updated: 12th February 2021
Acute prostatitis is a painful inflammation within the prostate that is usually accompanied by evidence of recent or ongoing infection.
Causes
Acute bacterial prostatitis is caused by urinary pathogens, most commonly Escherichia coli (up to 50% of infections), followed by Pseudomonas aeruginosa, Klebsiella, Enterococcus, Enterobacter, Proteus and Serratia species. Rarely, it can occur secondary to a sexually transmitted infection (STI) such as Chlamydia trachomatis, or Neisseria gonorrhoea.
Acute prostatitis can follow urethral instrumentation, trauma, bladder outflow obstruction, or dissemination of infection from elsewhere in the body. Men who have acute prostatitis following manipulation of the lower urinary tract are more likely to be infected with pathogens other than E. coli, to have multiple infections, and to develop a prostatic abscess.
Clinical features
Suspect acute prostatitis in a man who presents with signs and symptoms of:
- A urinary tract infection (UTI):
- Dysuria, frequency, urgency
- Prostatitis:
- Perineal, penile, or rectal pain
- Acute urinary retention, obstructive voiding symptoms (difficulty voiding, hesitancy, straining to urinate, weak stream)
- Low back pain, pain on ejaculation
- Tender, swollen, warm prostate (on gentle rectal examination)
- Bacteraemia:
- Rigors, arthralgia, or myalgia
- Fever, tachycardia
Investigations
In men suspected of having acute prostatitis:
- Arrange collection of a mid-stream urine (MSU) sample to confirm urinary tract infection (UTI) by dipstick, culture and sensitivity.
- Do not collect prostatic secretions as prostatic massage may lead to sepsis or prostatic abscess, is likely to be very painful, and is not needed for the diagnosis.
- Arrange blood cultures and full blood count.
- Conduct a physical examination — this should include the abdomen to detect a distended bladder or costovertebral angle tenderness, a genital examination, and a digital rectal examination (DRE):
- In men with acute bacterial prostatitis, the prostate will be tender, enlarged, or boggy.
- A DRE should be performed gently because vigorous prostatic massage can lead to sepsis.
- Consider screening for sexually transmitted infections (STIs), particularly in men considered to be at risk.
Differential diagnosis
- Benign prostatic hyperplasia (BPH)
- Chronic prostatitis
- Urinary tract infection
- Acute unilateral or bilateral epididymo-orchitis
- Prostate cancer
- Bladder cancer
- Colorectal cancer
Management
- Patients with acute prostatitis presenting with symptoms and signs of sepsis require parenteral antibiotics: a broad-spectrum penicillin, a third-generation cephalosporin, or a quinolone. As the patient improves, parenteral treatment can be discontinued and replaced with oral treatment.
- Less-severe cases of acute bacterial prostatitis without signs of sepsis can be treated with oral antibiotics. The recommended first-line treatment option is a quinolone. Treatment should generally continue for 2 to 4 weeks.
- Analgesia, laxatives and suprapubic catheterisation may be required for pain, painful defaecation, and acute urinary retention respectively.
- Rarely, a prostatic abscess may develop. Such patients require intravenous antibiotic therapy and may require surgical intervention.
Complications
Complications of prostatitis include:
- Acute urinary retention — this is a common complication of prostatitis and may be a presenting feature
- Bacteraemia
- Chronic prostatitis
- Epididymitis
- Prostatic abscess — this is a rare complication which may require surgical intervention
- Pyelonephritis
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
