Acute Bacterial Prostatitis

Overview

Acute bacterial prostatitis (ABP) is a sudden, severe bacterial infection of the prostate gland. Unlike chronic prostatitis, which develops gradually over months, acute prostatitis strikes rapidly with high fever, intense pain, and systemic illness. The NIH classifies this as Category I prostatitis.

This condition constitutes a medical emergency requiring prompt antibiotic treatment, often with hospitalization.

How Serious Is Acute Prostatitis?

Acute bacterial prostatitis demands immediate medical attention. Without treatment, the infection can progress to:

• Prostatic abscess: Pus collection requiring drainage
• Sepsis: Life-threatening bloodstream infection
• Chronic prostatitis: Long-term inflammation
• Urinary retention: Complete inability to urinate

With prompt treatment, most men recover fully. Hospital admission is common in the initial phase.

How Common Is Acute Prostatitis?

Acute bacterial prostatitis affects approximately 5-10% of men at some point in their lives. It occurs less frequently than chronic prostatitis but can strike at any age. Incidence peaks in men aged 30-40 and again after 60, with rising rates in older men linked to urological procedures.

Causes

Bacteria Responsible

Primary pathogens:

• Escherichia coli (E. coli): Accounts for 50-80% of cases
• Other gram-negative bacteria: Pseudomonas, Klebsiella, Proteus

Less common organisms:

• Gram-positive bacteria: Enterococcus, Staphylococcus
• Sexually transmitted pathogens: Chlamydia, Gonorrhea (more common in younger men)

Routes of Infection

Ascending infection represents the most common pathway. Bacteria travel upward from the urethra, often originating from a urinary tract infection.

Infected urine reflux occurs when urine flows backward into prostatic ducts during straining or with bladder outlet obstruction.

Hematogenous spread (via bloodstream) is rare but possible from distant infection sites.

Risk Factors

Urological procedures:

• Recent catheterization
• Cystoscopy
• Prostate biopsy
• Transurethral resection of the prostate (TURP)
• Any urethral instrumentation

Urinary conditions:

• Benign prostatic hyperplasia (BPH)
• Urethral stricture
• Bladder stones
• Urinary retention
• Current or recent UTI

Medical conditions:

• Diabetes mellitus
• Immunosuppression
• HIV infection

Symptoms

Onset Pattern

Symptoms develop suddenly over hours to days. The severity distinguishes acute prostatitis from chronic prostatitis, which manifests gradually.

Systemic Signs

Fever typically reaches 39-40°C (102-104°F), accompanied by:

• Shaking chills and rigors
• Profuse sweating
• Malaise and fatigue
• Generalized body aches
• Profound sense of being unwell

Urinary Symptoms

Pain manifestations:

• Burning during urination (dysuria)
• Suprapubic discomfort
• Perineal pain (between scrotum and anus)
• Lower back pain

Obstructive symptoms:

• Difficulty initiating urination
• Weak urinary stream
• Straining to void
• Complete urinary retention in severe cases

Irritative symptoms:

• Urinary frequency
• Urgency
• Nocturia

Additional Symptoms

• Painful ejaculation
• Blood in urine
• Blood in semen
• Rectal discomfort

When to Seek Emergency Care

Proceed to the emergency department immediately if you experience:

• High fever combined with urinary symptoms
• Inability to urinate
• Severe pelvic or abdominal pain
• Confusion or altered mental state
• Signs of sepsis: extreme temperatures, racing heart, rapid breathing, feeling critically ill

Acute prostatitis can progress to sepsis within hours. Do not delay seeking care.

Diagnosis

Clinical Evaluation

History taking focuses on symptom onset, fever pattern, urinary complaints, recent urological procedures, and sexual history.

Digital rectal examination (DRE) reveals an exquisitely tender prostate that may feel warm and swollen. The examination must be gentle—vigorous prostate massage is contraindicated as it risks causing bacteremia.

Laboratory Investigations

Urine studies:

• Urinalysis showing white blood cells and bacteria
• Urine culture to identify the causative organism and guide antibiotic selection

Blood tests:

• Elevated white blood cell count
• Raised inflammatory markers (CRP)
• Blood cultures if sepsis is suspected
• PSA levels (often markedly elevated—this does not indicate cancer in this context)
• Kidney function assessment

Imaging

Transrectal ultrasound or MRI is indicated when:

• Prostatic abscess is suspected
• The patient fails to respond to appropriate antibiotics

Differential Diagnosis

Conditions to exclude include epididymitis, urinary tract infection, prostatic abscess, and sepsis from other sources.

Treatment

Initial Management

Most patients require hospital admission for:

• Intravenous antibiotics
• IV fluid resuscitation
• Pain control
• Close monitoring

Outpatient treatment may be appropriate for less severe cases in reliable patients who can take oral medications, show no sepsis signs, and can return promptly if symptoms worsen.

Antibiotic Therapy

Empiric IV antibiotics (started before culture results):

• Ciprofloxacin or levofloxacin IV
• Gentamicin plus ampicillin
• Third-generation cephalosporin

Regimens are adjusted once culture and sensitivity results return.

Oral antibiotics follow IV therapy once improvement occurs:

• Ciprofloxacin 500mg twice daily, or
• Levofloxacin 500mg once daily

Total treatment duration: 4-6 weeks. The prostate’s poor antibiotic penetration necessitates this extended course. Stopping early risks chronic prostatitis development.

Supportive Measures

Pain management:

• NSAIDs (ibuprofen)
• Paracetamol
• Stool softeners to prevent straining

Urinary retention management: Catheterization becomes necessary when urination is impossible. Suprapubic catheter placement is preferred over urethral catheterization, as passing a catheter through the inflamed prostate can worsen infection.

Prostatic Abscess Management

Abscesses may not respond to antibiotics alone and require drainage via transrectal, transperineal, or transurethral approaches.

Recovery

Expected Timeline

• Fever should resolve within 48-72 hours of antibiotic initiation
• Pain decreases gradually
• Complete symptom resolution typically requires 2-4 weeks
• Full recovery is expected with appropriate treatment

Follow-Up Care

• Complete the entire 4-6 week antibiotic course
• Repeat urine culture after treatment completion
• Monitor for chronic prostatitis development
• PSA levels may remain elevated for weeks (recheck in 6-8 weeks)

Warning Signs Requiring Reassessment

• No improvement after 48-72 hours of antibiotics
• Recurrent fever after initial improvement
• Development of urinary retention
• Worsening pain
• New symptoms

Complications

Prostatic abscess develops when pus accumulates within the prostate. Suspect this complication when fever persists despite appropriate antibiotics.

Sepsis occurs when bacteria enter the bloodstream, causing a systemic inflammatory response that can rapidly become life-threatening.

Chronic prostatitis may follow inadequate treatment, leading to persistent symptoms that prove more difficult to manage.

Prevention

After urological procedures:

• Take prophylactic antibiotics as prescribed
• Ensure urine culture is performed before prostate biopsy
• Maintain sterile technique during procedures

General measures:

• Treat urinary tract infections promptly
• Manage BPH if present
• Maintain adequate hydration
• Avoid prolonged urinary retention

Key Points

1. Acute bacterial prostatitis is a medical emergency
2. High fever with urinary symptoms warrants immediate evaluation
3. Treatment requires 4-6 weeks of antibiotics—do not stop early
4. Hospital admission is common in the initial phase
5. Most men recover fully with prompt, appropriate treatment
6. Persistent fever despite antibiotics suggests prostatic abscess