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Can Urol Assoc J. 2011 Oct; 5(5): 306–315. PMCID: PMC3202001

doi: 10.5489/cuaj.11211 PMID: 22031609

Prostatitis
J. Curtis Nickel, MD, FRCSC

Background

Almost 9% of Canadian men experience some prostatitis symptoms over the course of a year,
in about 6%, the symptoms are a bother,1 with approximately a third experiencing a remission
of symptoms over a year during follow-up.2 Men with clinically significant prostatitis symptoms
account for about 3% of Canadian male outpatient visits3 and causes significant morbidity4 and
cost.5 Less than 10% of the patients suffer from acute or chronic bacterial prostatitis, condi‐
tions which are well-defined by clinical and microbiologic parameters and usually amenable to
antimicrobial therapy. Acute prostatitis is characterized by a severe urinary tract infection
(UTI), irritative and obstructive voiding symptoms with generalized urosepsis. Acute prostatitis
responds promptly to antimicrobial therapy, and is usually self-limiting. Chronic bacterial pro‐
statitis is usually associated with mild to moderate pelvic pain symptoms and intermittent
episodes of acute UTIs. Long-term antimicrobial therapy is curative in about 60% to 80% of
patients.

Most men with “chronic prostatitis” have chronic prostatitis/chronic pelvic pain syndrome
(CP/CPPS), characterized by pelvic pain (i.e., perineal, suprapubic, testicular, penile) variable
urinary symptoms and sexual dysfunction (primarily pain associated with ejaculation).6 The
National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) is a reliable means
of capturing the symptoms and impact of CP/CPPS.7 The etiology of this syndrome is not fully
known, the evaluation has been controversial and treatment is, unfortunately, frequently un‐
successful. Focused multimodal therapy appears to be more successful than empiric
monotherapy.

The recommendations presented in these guidelines were developed from North American
NIH consensus meetings,8 International Consultation on Urologic Disease (ICUD)/World Health
Organization (WHO) consensus meeting,9 European Guideline Committee recommendations,10
a recent comprehensive literature search performed by one of the authors11 and expert
Canadian panel discussion. Medline and EMBASE databases were used to identify relevant
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studies published in English from 1949 (for Medline) or 1974 (for EMBASE) until January 31,
2011. We used search terms and strategies for each database.11 The levels of evidence and
grades of recommendations were based on the ICUD/WHO modified Oxford Center for
Evidence-Based Medicine Grading System. These recommendations are summarized at the end
of this guideline document. Within the document, the level of evidence and recommendation
grade are included where appropriate and denoted as 3:A which means Level 3 evidence and
Grade A recommendation.

Definition

Prostatitis describes a combination of infectious diseases (acute and chronic bacterial prostati‐
tis), CPPS or asymptomatic prostatitis. The NIH classification of prostatitis syndromes12
includes:

Category I: Acute bacterial prostatitis (ABP) which is associated with severe prostatitis
symptoms, systemic infection and acute bacterial UTI.
Category II: Chronic bacterial prostatitis (CBP) which is caused by chronic bacterial infection
of the prostate with or without prostatitis symptoms and usually with recurrent UTIs caused
by the same bacterial strain.
Category III: Chronic prostatitis/chronic pelvic pain syndrome which is characterized by
chronic pelvic pain symptoms and possibly voiding symptoms in the absence of UTI.
Category IV: Asymptomatic inflammatory prostatitis (AIP) which is characterized by prostate
inflammation in the absence of genitourinary tract symptoms.

Evaluation

A mandatory history is required for all patients at time of evaluation (4:C). The following pre‐
senting symptoms should be elicited: pain location (severity, frequency, and duration), lower
urinary tract symptoms (obstructive/voiding and irritative/storage), associated symptoms
(fever, other pain syndromes) and impact on activities/quality life. A comprehensive systems
review should document past medical and surgical (particularly urologic) history, history of
trauma, medications and allergies.

1. Acute bacterial prostatitis (NIH category I)

a. Physical examination Mandatory (4:C): The abdomen, external genitalia, perineum and
prostate must be examined. Prostate massage during a digital rectal examination (DRE) is not
recommended.

b. Urine analysis and culture Mandatory (2:A)

c. Imaging Optional (2:A): A transrectal prostatic ultrasonography (TRUS) or computed tomog‐

raphy scan is indicated in ABP patients refractory to initial therapy to rule out prostate
abscess/pathology. Pelvic ultrasound (or bladder scan) is indicated in ABP patients with severe
obstructive symptoms, poor bladder emptying or physical examination findings of possible uri‐
nary retention. Initial imaging of the prostate is not recommended (3:B).

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d. Serum PSA Not recommended (3:C): Elevated prostate-specific antigen (PSA) associated
with ABP usually leads to confusion and worry.

2. Chronic bacterial prostatitis (NIH category II)

a. Physical examination Mandatory (4:C): This must include examination of the abdomen, exter‐
nal genitalia, perineum, prostate and pelvic floor.

b. Microbiological localization cultures of the lower urinary tract (4-Glass Test or 2-Glass Pre- and
Post-Massage Test [PPMT]) Recommended (3:A): The 4-glass test is the criterion standard for
the diagnosis of CBP. The 2- glass pre- and post-massage test (PPMT) is a simple and reason‐
ably accurate screen for bacteria. Microscopy is optional. Rationale and description can be
found in reference.6

c. Semen cultures Not recommended (3:D): Based on limited evidence, semen cultures have
not been shown to be significantly helpful in identifying men with CBP, unless the same organ‐
ism causing recurrent UTIs is cultured.

d. Transrectal prostatic ultrasonography Not recommended (3:B): A TRUS cannot be relied

upon for differential diagnosis of categories of prostatitis. A TRUS can be considered optional
(4:D) if there is a specific indication.

e. Urodynamics Optional (4:D): Uroflow may be helpful to confirm obstruction. Urodynamics

cannot be relied upon for differential diagnosis of categories of prostatitis, but may help docu‐
ment obstruction and/or bladder problems.

3. Chronic prostatitis/chronic pelvic pain syndrome (NIH category IIIA, IIIB)

a. Symptom scoring questionnaire Recommended (3:A)- the NIH-CPSI (Fig. 1) has become the
established international standard for symptom evaluation (not for diagnosis) of prostatitis.
The index has been shown to be reliable and can evaluate the severity of current symptoms
and be used as an outcome measure to evaluate the longitudinal course of symptoms with time
or treatment.

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Fig. 1.

The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) captures the three most im‐
portant domains of the prostatitis experience: pain (location, frequency and severity), voiding (irritative and
obstructive symptoms) and quality of life (including impact). This index is useful in research studies and
clinical practice. Adapted from Litwin et al. 7 Reprinted with permission.

b. Physical examinations Mandatory (4:C): Examination of abdomen, external genitalia, per‐

ineum and prostate is mandatory. Exacerbation of typical pelvic pain with normal DRE pres‐
sure is helpful in determining prostate centricity, while evaluating myofascial trigger points
and/or possible musculoskeletal dysfunction of the pelvis and pelvic floor during DRE is be‐
lieved to be helpful in treatment decisions.

c. 4-Glass test and 2-glass pre- and post-massage test (PPMT) Recommended (3:A): Culture of
the lower urinary tract urine specimens is recommended. The 4-glass test is the criterion stan‐
dard to rule out CBP. The 2-glass PMT is a simple and reasonably accurate screen for bacteria.
A rationale and description for this recommendation are available.6 At this time, there is no evi‐
dence that suggests that microscopy of the EPS or urine sediment adds any clinical value (mi‐
croscopy optional).

d. Culture and/or microscopic examination of semen Not recommended (3:D)

e. Cystoscopy Not recommended (4:D) for routine evaluation. Optional (4:D): For selected pa‐
tients. Endoscopy may be indicated in selected patients with obstructive voiding symptoms (re‐
fractory to medical therapy), patients with hematuria or other suspected lower urinary tract
pathology.

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f. Transrectal ultrasound Not recommended (3:B) in routine practice, unless there is a specific
indication.

g. CT scan and/or magnetic resonance imaging (MRI) Not recommended (3:B): At present,
value is unknown.

h. Urodynamics Optional (3:C): In selected men with obstructive voiding symptoms, it is rea‐
sonable to consider urodynamic evaluation (e.g., flow rates, post-void residual, pressure flow
studies).

i. Serum PSA Levels Not recommended (3:B): There is no evidence that serum PSA levels in pa‐
tients with CP/CPPS will help diagnosis and direct therapy. Indications for serum PSA determi‐
nations should be the same as for men without CP/CPPS.

j. Psychological Assessment Optional (3:B): There is accumulating evidence that psychosocial

parameters, such as depression, maladaptive coping mechanisms (catastrophizing, resting as a
coping mechanism) and poor social support impact symptoms and results of therapy. The
physician should screen for these psychological problems.

There is a practical algorithm to assess a man presenting with presumed CP/CPPS (Fig. 3).

Fig. 3.

A best-evidence approach algorithm to manage chronic prostatitis/chronic pelvic pain syndrome.

*
amitriptyline, gabapentin, biofeedback, massage therapy, acupuncture, neurostimulation

4. Asymptomatic prostatitis (NIH category IV)

Investigations Not recommended (3:C): While some evidence suggests that this category may
have biological relevance, at this time there is no evidence that determination of asymptomatic
prostatitis has any clinical relevance.

Treatment

1. Acute bacterial prostatitis (NIH category I)

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ABP can be a serious infection with fever, intense local pain and general symptoms. Septicemia
and urosepsis are always a potential risk. The following factors must be taken in account when
treating ABP: potential urosepsis, choice of antimicrobial agent, urinary drainage, risk factors
justifying hospitalization and auxiliary measures intended to improve treatment outcomes.13

a. Antimicrobial Therapy (2:A) The choice and duration of antimicrobial therapy for ABP are
based on experience and expert opinion and are supported by many uncontrolled clinical
studies.14,15 For initial treatment of severely ill patients, the following regimens are recom‐
mended: intravenous administration of high doses of bactericidal antimicrobials, such as
aminoglycosides in combination with ampicillin, a broad spectrum penicillin in combination
with a beta-lactamase inhibitor, a third-generation cephalosporin or a fluoroquinolone is re‐
quired until defeverescence and normalization of associated urosepsis (this recommendation
is based on treatment of complicated UTIs and urosepsis). Patients who are not severely ill or
vomiting may be treated with an oral fluoroquinolone.14,15 Trimethoprim-sulfamethoxazole
(TMP/SMX) is no longer recommended as first line empirical therapy in areas where TMP/SMX
resistance for E. coli, the most frequent pathogen, is greater than 10% to 20%.15–19 Treatment
should continue for 2 to 4 weeks.14,15

b. Urinary drainage (3:B) A single catheterization with trial of voiding or short-term small cal‐
iber urethral catheterization is recommended for patients with severe obstructive voiding
symptoms or urinary retention. Suprapubic tube placement is optional for patients who cannot
tolerate a urethral catheter.

c. Hospitalization (3:B) Hospitalization is mandatory in cases of hyperpyrexia, prolonged vom‐

iting, severe dehydration, tachycardia, tachypnea, hypotension and other symptoms related to
urosepsis. Hospitalization is recommended in high-risk patients (diabetes, immunosuppressed
patient, old age or prostatic abscess) and those with severe voiding disorders.13

d. Drainage of prostate abscess (4:A) Incision and drainage of prostate abscess are required in
selected treatment refractory patients. Transurethral route appears to be modality of choice
but abscess may be drained via perineum, rectum or transperineal route.

d. Auxiliary measures Nonsteroidal anti-inflammatory agents have been suggested for reduc‐
ing symptoms including fever.13–15 Alpha-blockers may be considered, particularly in men with
moderately severe obstructive voiding symptoms to reduce the risk of urinary retention and
facilitate micturition.13–15

2. Chronic bacterial prostatitis (NIH category II)

a. Antimicrobial therapy (2:A) Because of their unique and favourable pharmacokinetic proper‐
ties, their broad antibacterial spectra and comparative clinical trial evidence, the fluoro‐
quinolones are the recommended agents of choice for the antimicrobial treatment of
CBP.14,15,17,18 Data from CBP fluoroquinolone treatment trials with a follow-up of at least 6
months support the use of flouroquinolones as first-line therapy.20–28 The recommended 4- to
6-week duration of antimicrobial treatment is based on experience and expert opinion and is
supported by many clinical studies.14,15,17,18 In general, therapeutic results (defined as bacte‐

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rial eradication) are good in CBP due to E. coli and other members of the family
Enterobacteriaceae. CBP due to P. aeruginosa and Enterococci shows poorer response to antimi‐
crobial therapy.18

CBP associated with a confirmed uropathogen that is resistant to the fluoroquinolones can be
considered for treatment with trimethoprim-sulfamethoxazole (or other antimicrobials), but
the treatment duration should be 8 to12 weeks.18

b. Alpha-Blockers (3:C) The combination of antimicrobials and alpha-blockers has been sug‐
gested to reduce the high recurrence rate28 and this combination of two therapeutic regimens
is considered optional for in-patients with obstructive voiding symptoms.

c. Treatment refractory cases For treatment refractory patients with confirmed uropathogen
localized to the prostate, the following are optional treatment strategies:

intermittent antimicrobial treatment of acute symptomatic episodes (cystitis) (3:A);

low-dose antimicrobial suppression (3:A); or
radical TURP or open prostatectomy if all other options have failed (4:C).

3. Chronic prostatitis/chronic pelvic pain syndrome (NIH category III)

The introduction of an internationally accepted classification system,12 a validated outcome in‐

dex, the NIH-CPSI,7 and the significant number of randomized placebo controlled clinical trials
published over the last decade and a half11 has permitted best-evidence based guideline rec‐
ommendations. Twenty-three clinical trials29–54 were available at time of this guideline devel‐
opment. These English-language trials evaluated medical therapies using a prospective, ran‐
domized controlled design; these trials were used to support these recommendations. These
have been recently reviewed and analyzed.11 We also used a literature search strategy.11 In ad‐
dition, a best-evidence based treatment algorithm was used (Fig. 3).

a. Antimicrobials Antimicrobials cannot be recommended for men with longstanding, previ‐

ously treated CP/CPPS (1:A). However, uncontrolled clinical studies suggest that some clinical
benefit can be obtained with antimicrobial therapy in antimicrobial naïve early onset prostatitis
patients (4:D).

b. Alpha-blockers Alpha-blockers cannot be recommended as a first line monotherapy (1:A).

However, there is some evidence that alpha-blocker naïve men with moderately severe symp‐
toms who have relatively recent onset of symptoms may experience benefit (1:A). Alpha-
blocker therapy appears to provide benefit in a multimodal therapeutic algorithm for men with
voiding symptoms (2:C)). Alpha-blockers must be continued for over 6 weeks (likely over 12
weeks).

c. Anti-inflammatory Anti-inflammatory therapy is helpful for some patients, but is not recom‐
mended as a primary treatment (1:B); however, it may be useful in an adjunctive role in a mul‐
timodal therapeutic regimen (2:C).

d. Phytotherapies Phytotherapies (specifically quercetin and the pollen extract, cernilton) are
optional recommendations for first line (2:B) and combination multimodal therapy (3:C).

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e. Other medical therapies Other medical therapies, such as 5-alpha-reductase inhibitor ther‐
apy, pentosanpolysulfate and pregabalin, while not recommended as primary monotherapy
(1:A), may provide benefit in selected patients (older men with LUTS for 5-ARI therapy, men
with associated pain perceived bladder pain and irritative voiding symptoms for pentosanpoly‐
sulfate and neuropathic type pain for pregabalin).

f. Other potential medical therapies Muscle relaxants, saw palmetto, corticosteroids, and tri‐
cyclic antidepressants have all been suggested6 and used, but recommendations will have to
wait for results from properly designed randomized placebo controlled trials (4:D).

g. Physiotherapies A number of physical therapies have been recommended,6 but they also
suffer from a lack of prospective controlled data obtained from properly designed controlled
studies. Prostatic massage, perineal or pelvic floor massage and myofascial trigger point re‐
lease has also been suggested as a beneficial treatment modality for patients, however focused
pelvic physiotherapy has yet to be shown to provide more benefit compared to SHAM physio‐
therapy. Biofeedback, acupuncture and electromagnetic therapy also show promise, but like all
the other physical therapeutic modalities, require sham controlled trials before recommenda‐
tions can be made (3:C).

h. Psychotherapies Psychological support and therapy has been advocated based on new psy‐
cho-social modelling of this syndrome.55 This treatment ideally would include a cognitive be‐
havioral therapy program. A referral to a psychologist or psychiatrist should be considered
mandatory in patients with severe depression and/or suicidal tendencies.

i. Surgery The evidence for surgical therapies has been reviewed.6 A number of minimally in‐
vasive therapies such as balloon dilation, neodymium:Yag laser, transurethral needle ablation,
microwave hyperthermia and thermotherapy have been suggested (at this time, not recom‐
mended, 2:A). Further assessment of heat therapy employing sham controls, standardized in‐
clusion exclusion criteria and validated symptom outcome measures are recommended.
Pudendal nerve blocks or neurolysis surgery have been suggested for CPP that can be shown
to be secondary to pudendal nerve entrapment (3:C). Other surgery, such as radical
transurethral resection of the prostate and total prostatectomy, should not be encouraged and
is not recommended (4:D) at this time for CP/CPPS since no definitive clinical series or long-
term follow-up has ever been presented.

j. Multimodal Therapy (UPOINT) A number of uncontrolled clinical studies have strongly sug‐
gested that multimodal therapy is more effective than monotherapy in patients with long-term
symptoms.56,57 Individualized personal therapy algorithms directed toward clinically defined
presenting phenotypes (UPOINT) have been proposed58 and the early results of such a strat‐
egy look promising.59 Based on the fact that monotherapies provide (at best) modest efficacy, a
multimodal approach using specific clinical phenotypes to choose therapies is considered an
optional recommendation.58 An algorithm has been proposed (Fig. 4).

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Fig. 4.

A clinical phenotype directed treatment (UPOINT) approach for chronic prostatitis/chronic pelvic pain
syndrome.

4. Asymptomatic prostatitis (NIH category IV)

Therapy is not indicated (3:A) since these patients by definition are asymptomatic. However,
antimicrobial therapy for selected patients with category IV prostatitis associated with elevated
PSA, infertility and those planned for prostate biopsy may warrant consideration (3:C).

Fig. 2.

Diagnostic algorithm for a patient presenting with a chronic prostatitis syndrome.

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Table 1.

Summary of recommendations (Level of Evidence: Grade of Recommendation)

EVALUATION

I. Acute Bacterial Prostatitis (NIH Category I)

1. History (Mandatory 4:C)

2. Physical examination (Mandatory 4:C)
3. Urinalysis and culture/sensitivity (Mandatory 2:A)
4. Initial imaging of the prostate (not recommended 3:B) Ultrasound optional (2:A) if
suspicion for prostatic abscess is entertained.
II. Chronic Bacterial Prostatitis (NIH Category II)

1. History (Mandatory 4:C))

2. Physical examination (Mandatory 4:C))
3. 4-glass or 2-glass test for culture. (Recommended 3:A)
4. Culture of semen (Not recommended 3:D)
5. Imaging of the prostate (Not recommended 3:B); optional (4:D) only in highly
selected patients
6. Urodynamics (Optional in selected cases only 4:D)
III. Chronic Prostatitis/Chronic Pelvic Pain Syndrome (NIH Category III)

1. History (Mandatory 4:C)

2. The NIH-CPSI instrument (Recommended 3:A)
3. Physical examination (Mandatory 4:C)
4. 4-glass or 2-glass test for WBC count and culture (Recommended 3:A)
5. Semen analysis and culture (Not recommended 3:D)
6. Flow rate, post-void residual and other urodynamic studies (Optional 3:C)
7. Serum PSA (Not recommended 3:B)
8. Routine imaging of the prostate (Not recommended 3:D)
9. Cystoscopy (Not recommended 4:D)
10. Psychological evaluation in selected patients (Optional 3:B)
IV. Asymptomatic Prostatitis (NIH Category IV)

1. No evaluation unless considering antimicrobial therapy for elevated PSA or

infertility. (Recommended 3:C)

TREATMENT

I. Acute bacterial prostatitis (NIH Category I)

Footnotes

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Competing interests: J. Curtis Nickel reports being an investigator/consultant for Glaxo-Smith-Kline, Johnson and
Johnson, Pfizer, Watson, Ferring, Taris and consultant for Farr Labs, Astellas, Triton, Trillium Therapeutics, Cernelle.

This paper has been peer-reviewed.

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