CME

Acute and Chronic Prostatitis

John C. Lam, MD, and William Stokes, MD

Prostatitis is a common clinical syndrome classified into four categories: acute bacterial, chronic bacterial, chronic pros-
tatitis/chronic pelvic pain syndrome, and asymptomatic. Bacterial prostatitis (acute and chronic) is primarily diagnosed
with history and microbiologic studies, although physical examination can be helpful to localize infection within the
genitourinary system. Bacterial prostatitis is treated with antibiotics; the span of treatment is guided by the duration
of symptoms and presence of complications. Chronic prostatitis/chronic pelvic pain syndrome is the most common
form of prostatitis and is a diagnosis of exclusion with no standardized treatments. Asymptomatic prostatitis does not
require treatment and is usually diagnosed incidentally during the workup for other urologic presentations.

Am Fam Physician. 2024;110(1):45-51. Copyright © 2024 American Academy of Family Physicians.

P rostatitis encapsulates a spectrum of clinical syndromes

that affects approximately 10% to 15% of individuals
assigned male at birth.1-3 It presents with varying degrees of
incidentally identified during investigation for reproductive
tract disorders or other urinary tract pathologies.

lower urinary tract symptoms (e.g., obstructive, irritative, ACUTE BACTERIAL PROSTATITIS
storage related), pelvic pain, sexual dysfunction, and systemic Diagnosis
features. The National Institutes of Health organizes prostatitis Pyelonephritis and acute bacterial prostatitis are recognized
into four categories. Categories I and II constitute 10% of cases complications of lower urinary tract infections. Pyelonephritis
and include acute and chronic bacterial prostatitis, respectively. occurs via microbial ascension from the lower urinary tract
Category III (chronic prostatitis/chronic pelvic pain syndrome to the kidney, and acute bacterial prostatitis is an infection
[CPPS]) and category IV (asymptomatic inflammatory pros- spread from the lower urinary tract to the prostate. Both syn-
tatitis) are noninfectious and comprise the remaining 90% of dromes are characterized by lower urinary tract symptoms (e.g.,
cases.4 Identifying prostatitis as bacterial (categories I and II) dysuria, urinary frequency and urgency, suprapubic pain) and
or nonbacterial (categories III and IV) is critical for timely an abrupt onset of systemic symptoms of infection (e.g., fever,
treatment and appropriate antibiotic use (Table 1).5 chills, nausea, vomiting).
Bacterial prostatitis is an infection of the prostate gland. It Unlike pyelonephritis, acute bacterial prostatitis typically
can occur via ascending infection from the urethra, inoculation lacks flank pain and costovertebral angle tenderness; instead,
from direct manipulation of the prostate gland (e.g., biopsy), it manifests with perineal or suprapubic discomfort and urinary
or hematogenous seeding.6 Commensal organisms within the storage symptoms, including dribbling or hesitancy, caused by
gastrointestinal tract, particularly Enterobacterales (e.g., Esche- the inflamed prostate obstructing the urethral canal. Penile and
richia coli, Klebsiella, Proteus) are the most common pathogens scrotal pain may occur but are described less often. Pain with
implicated in cases caused by ascending infection from the
urethra.7 Other gastrointestinal flora, although less common,
include gram-positive cocci such as Enterococcus.
JOHN C. LAM, MD, FRCPC, is a clinical instructor in the
Infectious prostatitis from other gram-positive cocci, such
Division of Infectious Diseases, Department of Medicine,
as Staphylococcus aureus and coagulase-negative staphylococci,
University of California Los Angeles.
usually occur from urinary tract manipulation (e.g., catheters)
WILLIAM STOKES, MD, FRCPC, is a clinical lecturer
or hematogenous sources. Bacterial prostatitis after prostate
at the Provincial Laboratory for Public Health, Alberta
biopsy is more likely caused by drug-resistant organisms due to
Precision Laboratories, Canada; the Department of
the widespread use of prophylactic antibiotics (typically fluoro-
Pathology and Laboratory Medicine at the University of
quinolones) before the procedure.8 Uncommon causes of bac-
Alberta, Edmonton, Canada; and the Division of Infec-
terial prostatitis include Chlamydia trachomatis, Mycobacterium
tious Diseases, Department of Medicine, University of
tuberculosis, and Burkholderia pseudomallei.9 Other organisms
Alberta, Edmonton, Canada.
that less commonly cause prostatitis, such as fungi, usually
occur in patients who are immunocompromised.10 Author disclosure: No relevant financial relationships.
Chronic prostatitis/CPPS is poorly understood, lacks uni- Address correspondence to John C. Lam, MD, FRCPC,
versal diagnostic criteria, and is associated with negative at johlam@[Link].
impacts on quality of life. Asymptomatic prostatitis is usually

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ejaculation may occur, although patients are typically too ill can help distinguish acute bacterial prostatitis from other
to pursue sexual activities.11 conditions.7,13,14
Acute bacterial prostatitis can be suspected based on these
symptoms and confirmed with appropriate urine studies (e.g., Treatment
urinalysis, urine culture), which can also be used to guide ther- Treatment of acute bacterial prostatitis is similar to that of com-
apy. Bacteremia occurs as a complication of acute bacterial pros- plicated urinary tract infections. Empiric antibiotic therapy is
tatitis in 20% of inpatient cases.12 directed by local antibiogram data and severity of illness, with
Digital rectal examination reveals a prostate that is enlarged, intravenous medications preferred in patients who are septic,
boggy, and tender. Prostate massage, in which pressure is hemodynamically unstable, or at risk of multidrug-resistant
applied to the prostate during palpation, is not recommended, organisms resistant to oral antibiotics. Prostatic inflammation
because it may cause bacterial seeding and subsequent clin- in acute bacterial prostatitis enhances drug penetration to pros-
ical deterioration. Although the diagnosis of acute bacterial tate tissue. Oral antibiotics with effective prostate penetration
prostatitis can be confirmed without digital rectal exam- (e.g., fluoroquinolones, trimethoprim/sulfamethoxazole, tet-
ination, this practice is safe when performed gently, and it racyclines) are highly effective options if the patient is stable.15

TABLE 1

Evaluation and Treatment of Prostatitis

Syndrome Differential diagnosis Symptoms Physical examination

Acute bacte- Acute cystitis, prostatic abscess, Genitourinary: straining, urgency, Prostate that is tender,
rial prostatitis pyelonephritis dysuria, hesitancy, frequency, obstruc- boggy, and enlarged on
tion, irritation digital rectal examina-

Systemic: fever, malaise, arthralgia, tion; distended bladder;

myalgia, intense suprapubic pain, mildly prostate massage is not

to acutely ill appearance, chills, nausea, recommended

emesis, signs of sepsis (tachycardia and

hypotension)

Chronic bacte- Benign prostatic hyperplasia, stones Irritative voiding symptoms; testicular, Prostate can feel nor-
rial prostatitis or foreign body within the urinary low back, or perineal pain; recurrent mal, tender, or boggy on
tract, bladder cancer, prostatic urinary tract infection; urethritis; epidid- digital rectal examina-
abscess, enterovesicular fistula ymitis; distal penile pain tion; prostate massage
can be considered for
2-glass test

Chronic pelvic Benign prostatic hyperplasia, void- Chronic pelvic pain and/or sexual dys- Abdominal and digital
pain syndrome ing dysfunction, bladder or prostate function and possible voiding symptoms rectal examination to
(inflammatory cancer, prostatic or müllerian duct exclude underlying
and nonin- remnants, interstitial cystitis, radiation pathology; varying
flammatory) cystitis, eosinophilic cystitis, chronic degrees of tenderness;
proliferative cystitis, neuropathic pain, findings are variable
ejaculatory duct obstruction

Asymptomatic —
­­ None; incidental finding during evaluation Not applicable
prostatitis for other conditions (e.g., infertility or
elevated prostate-specific antigen level)

*—Selection of empiric therapy dependent on local antibiogram.

†—Used to establish diagnosis and determine treatment effect.

Adapted with permission from Sharp VJ, Takacs EB, Powell CR. Prostatitis: diagnosis and treatment. Am Fam Physician. 2010;82(4):400-401.

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 PROSTATITIS

Two weeks of antibiotic therapy is generally sufficient.7,16 catheterization), or relapsed symptoms despite an appropriate
Figure 1 provides an overview of diagnosis and treatment of antibiotic course.18 Patients should also be assessed for urinary
acute bacterial prostatitis. retention, which can increase the likelihood of developing
prostatitis.
Special Considerations
Prostate abscesses occur in 3% to 6% of acute bacterial prostati- CHRONIC BACTERIAL PROSTATITIS
tis cases and benefit from radiology-guided or surgical drainage Diagnosis
with prolonged antibiotics in consultation with urology and Most cases of chronic bacterial prostatitis develop as primary
infectious disease specialists.13,17 Evaluation for abscesses with infections, although 8% occur as a complication of acute bac-
transrectal ultrasonography or computed tomography should be terial prostatitis.6 Symptoms of chronic bacterial prostatitis
considered in patients with higher likelihood of abscess devel- mimic those of acute bacterial prostatitis, except they are more
opment. This includes ill patients who require hospitalization insidious and typically not associated with systemic symptoms
and patients with ongoing fevers beyond 48 hours, recent
urinary tract manipulation (e.g., prostatic biopsy, cystoscopy,
FIGURE 1

History and physical examination

Urine culture for all patients and

Evaluations Treatment and management postvoid residual, if indicated

Urine culture Empiric antibiotics targeting Entero-

Complete blood bacterales while awaiting culture

Mildly ill Moderately to severely ill
count with results*

differential, Carbapenems
electrolytes, Empiric ciprofloxacin, Empiric ceftriaxone, 2 g
Ceftriaxone
500 mg orally intravenously every 24 hours;
creatinine
Fluoroquinolones twice per day while in those at risk of infection with
Blood culture awaiting culture drug-resistant organisms, treat
Duration of treatment: ≥ 14 days results, for 14 days with ertapenem, 1 g intravenously
(if systemically
every 24 hours or meropenem,
unwell) Consider postvoid residual to assess
500 mg intravenously every 6 hours
underlying urinary obstruction

Urine culture Fluoroquinolone (first-line),

Consider 2-glass trimethoprim/sulfamethoxazole, doxy-

Slow clinical improvement Responding
test cycline, fosfomycin adequately
to treatment
Duration of treatment: 4 weeks if using
Computed tomography
fluoroquinolone or 6 weeks for others of abdomen and pelvis or
Consider postvoid residual to assess transrectal ultrasonography

underlying urinary obstruction

National Multimodal: combination of nonphar-

Institutes of macologic therapy and nonantibiotic No complications Complications (e.g.
prostatic abscess)
Health-Chronic medication
Prostatitis Modify antibiotics
Symptom Index,† based on culture Urology and
results infectious disease
2-glass test
Duration: 14 days consultation

Semen analysis, No specific treatment required; treat-

prostate biopsy ment depends on underlying conditions
Modify antibiotics based on culture results
and reasons for initial evaluation
Duration: 14 days, but longer if
complications are detected on imaging

Diagnosis and treatment of acute bacterial prostatitis.

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(e.g., fever, chills, nausea, vomiting). As with acute bacterial Meares-Stamey 4-glass test or the modified 2-glass test, can
prostatitis, additional symptoms of prostatitis are what differ- confirm chronic bacterial prostatitis20 (Figure 25). The mod-
entiate chronic bacterial prostatitis from other urinary tract ified 2-glass test is most commonly used because it is easier
infections. The most common clinical presentation of chronic to perform and its accuracy is similar to the Meares-Stamey
bacterial prostatitis is relapsing urinary tract infections (from 4-glass test.21 Both tests have high specificity but low sensitiv-
the same organism) despite initial resolution of urinary symp- ity. For either test, the sensitive nature of the maneuver and
toms with antibiotic treatment. Other diagnoses, including the time required to conduct it are barriers for most physi-
infected renal or bladder stones and bladder outflow obstruc- cians. However, these tests can help localize genitourinary
tion (e.g., bladder diverticula, incomplete bladder emptying) infections when there is a lack of diagnostic clarity and help
are considerations with recurrent infections of the urinary tract differentiate chronic bacterial prostatitis from noninfectious
from the same organism. prostatitis.
Chronic bacterial prostatitis should be suspected in patients
with recurrent, episodic, and symptomatic genitourinary Treatment
infections for at least 3 months.19 Palpation of the prostate Treatment of chronic bacterial prostatitis includes a prolonged
may help confirm the diagnosis and is safe to perform due course (at least 3 to 6 weeks) of oral antibiotics that penetrate
to the prostate being less inflamed than with acute bacte- the alkaline environment of the chronically infected prostate.
rial prostatitis. The prostate may be tender or boggy, but it Because patients with chronic bacterial prostatitis are typi-
can also feel normal. Isolating microbial pathogens from cally systemically well, intravenous antibiotics are reserved for
prostatic secretions or after prostate palpation, using the patients who cannot otherwise pursue oral therapy (e.g., due

FIGURE 2

EPS

VB1

VB2 VB3
© Renee Cannon

Meares-Stamey 4-glass test.

The 4-glass test is performed by sequentially collecting four separate urine samples. The first two samples represent urethral collection (VB1) and
midstream urine (VB2). Subsequently, a prostate massage is performed for expressed prostatic secretions (EPS) followed by urine collection (VB3).
Chronic bacterial prostatitis can be diagnosed if the bacterial colony count of the EPS or VB3 exceeds the pre-prostatic massage VB2 by 10-fold.
The modified 2-glass test is performed by comparing VB2 with VB3. Prostatitis is not excluded based on the modified 2-glass test due to low sensi-
tivity. However, specificity of the modified 2-glass test is high, with one study reporting 100% specificity.21

Illustration by Renee Cannon

Adapted with permission from Sharp VJ, Takacs EB, Powell CR. Prostatitis: diagnosis and treatment. Am Fam Physician. 2010;82(4):399.

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 PROSTATITIS

to multidrug resistance). Oral therapies with the most evidence Special Considerations
for effectiveness include fluoroquinolones, trimethoprim/sulfa- Patients with chronic bacterial prostatitis should be screened
methoxazole, and doxycycline. for potential causes and complications. Urinary retention
Fluoroquinolones are first-line agents because of their predisposes individuals to recurrent genitourinary tract infec-
spectrum of activity against uropathogens, excellent pene- tions, including chronic bacterial prostatitis. It can also cause
tration into prostatic tissue, and high oral bioavailability.22 symptoms similar to chronic bacterial prostatitis (e.g., supra-
Although supporting evidence is limited, fosfomycin is being pubic discomfort, bladder irritation, urinary dribbling). Uri-
increasingly used because of its effective prostatic penetration nary retention can be assessed with measurement of postvoid
and effectiveness for common multidrug-resistant pathogens bladder residual via ultrasonography. Ultrasonography of the
(e.g., extended-spectrum beta-lactamase E. coli).4 Linezolid urinary tract can be helpful to assess nonprostatic obstructive
and macrolides have reliable prostatic pen-
etration but do not include a spectrum of
TABLE 2
activity against the most common patho-
gens associated with chronic bacterial
prostatitis.23 Pharmacologic Treatment Options for
Oral beta-lactams such as penicillin Chronic Bacterial Prostatitis
and cephalosporin derivatives have vary-
Organism Duration
ing degrees of prostatic penetration with
susceptibility profile Antibiotic choices of treatment
chronic bacterial prostatitis because the
lack of prostate inflammation causes less Ciprofloxacin-sensitive Ciprofloxacin, 500 mg orally 4 weeks
favorable pharmacokinetic conditions. twice per day
High-dose oral beta-lactams are being
or
used more often to treat other deep-seated
infections, such as osteomyelitis. Although Levofloxacin, 500 to 750 mg

evidence is lacking for the use of high-dose orally once per day

oral beta-lactams to treat chronic bacterial

Ciprofloxacin-resistant, TMP/SMX, 160/800 mg orally 6 weeks
prostatitis, they may be an appropriate
TMP/SMX–sensitive twice per day
option if none of the other oral options
mentioned can be used. Infectious disease Ciprofloxacin-resistant, Doxycycline, 100 mg orally 6 weeks
consultation is strongly recommended TMP/SMX–resistant, twice per day
before starting treatment with high-dose doxycycline-sensitive
oral beta-lactams.
Treatment duration is 4 weeks with a Ciprofloxacin-resistant, Fosfomycin, 3 g orally every 1 to 6 weeks
fluoroquinolone and 6 weeks with other TMP/SMX–resistant, 3 days
antibiotics (Table 24). Treatment duration doxycycline-resistant,
can be extended to 12 weeks if the patient fosfomycin-sensitive*
has had a prior relapse of chronic symp-
toms after 4 to 6 weeks of antibiotics. For Chlamydial prostatitis Azithromycin, 500 mg once per 3 weeks
patients with prostatic abscesses, source day or three times per week (in
control via drainage should be pursued if the first 3 consecutive days of
possible. Antibiotics can be prolonged until each week)†
repeat radiologic imaging is reassuring, or
as guided by urology or infectious disease Relapsing chronic bac- Antibiotics as indicated 12 weeks
expert consultation. terial prostatitis despite above; computed tomography
Chronic bacterial prostatitis caused by adequate treatment of abdomen and pelvis and
C. trachomatis requires 3 weeks of azithro- urologic or infectious diseases
mycin or 4 weeks of doxycycline. Pros-
22 consultation also recommended
tatic infection from less common microbial Note: Treat according to susceptibility results provided. Dosages provided are for patients
causes, such as S. aureus from seeding of a with normal renal function.
disseminated infection, M. tuberculosis, or TMP/SMX = trimethoprim/sulfamethoxazole.
B. pseudomallei, should be treated in consul- *—Exception to susceptibility testing could be oral fosfomycin for Enterobacterales with-
tation with an infectious disease specialist. out susceptibility breakpoints (e.g., Klebsiella).
Infectious disease consultation should also †—Doxycycline, 100 mg twice per day for 4 weeks, can also be used.
be sought for treatment of immunocompro- Information from reference 4.
mised patients.

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 SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating Comments

Prostate massage is not recommended in patients suspected to have acute C Expert consensus
bacterial prostatitis.7,13,14

For acute bacterial prostatitis, 2 weeks of an antibiotic that targets uro- B Prospective randomized trial
pathogens is recommended.7,16 and expert consensus

The modified 2-glass test to compare urine before and after prostate mas- C Cohort study with disease-
sage can be used to localize urinary tract inflammation in the prostate when oriented outcomes
there is uncertainty about the diagnosis of chronic bacterial prostatitis.21

For chronic bacterial prostatitis, fluoroquinolones are first-line treatment B Systematic review
due to their spectrum of activity against uropathogens, high oral bioavail-
ability, and ability to penetrate prostatic tissue.22

Severe symptoms or slow clinical improvement should prompt imaging B Retrospective cohort study
studies to identify complications, including prostatic abscesses.17,18

Antibiotics are not recommended in chronic prostatitis/chronic pelvic pain B Randomized trial, clinical
syndrome or asymptomatic inflammatory prostatitis.14,24,28,32 reviews

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-ori-
ented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to [Link]
org/afpsort.

pathology. Additional imaging with computed tomography or further workup (e.g., cystoscopy, urodynamic studies) may
transrectal ultrasonography is typically reserved for patients be required.
with suspected complications, such as prostatic abscess.17,18 The
use of prostate-specific antigen as a marker to predict relapse Treatment
is not validated.7 To guide treatment, the UPOINT phenotype system catego-
rizes individuals into six domains: urinary, psychosocial, organ
CHRONIC PROSTATITIS/CHRONIC PELVIC specific, infectious, neurologic/systemic, and tenderness of skel-
PAIN SYNDROME etal muscles.26 A variety of medications, including antibiotics,
Diagnosis anti-inflammatories, alpha blockers, 5-alpha reductase inhib-
Chronic prostatitis/CPPS is a diagnosis of exclusion, charac- itors, antidepressants, and neuroleptics have been tested with
terized by pelvic pain with or without urinary symptoms or varying success.24,27 Antibiotic therapy has not been shown to
sexual dysfunction (e.g., ejaculatory pain, premature ejacula- be superior to placebo for chronic prostatitis/CPPS.28 Some
tion, erectile dysfunction) for 3 of the preceding 6 months. patients describe benefit from antibiotics, but it is likely from
Despite the nomenclature, the prostate’s role in these symp- the anti-inflammatory properties of those medications. Antibi-
toms is unclear.24 otics are not recommended without proven infection.24
Chronic prostatitis/CPPS is diagnosed by excluding dis- Nonpharmacologic therapies, including physiotherapy, acu-
eases with similar presentations, such as bacterial prosta- puncture, and cognitive behavior therapy, have varying degrees
titis, renal stones, orchitis, inguinal lymphadenopathy, or of effectiveness for chronic prostatitis/CPPS and continue to be
abdominal hernias. 25 The National Institutes of Health- studied.29-31 A multidisciplinary approach with urology, pain
Chronic Prostatitis Symptom Index is a validated tool to specialists, and allied health professionals should be considered
assess symptoms and quality of life in patients with the con- for treatment.
dition.26 Examination may reveal myofascial tenderness of
the pelvic floor with varying degrees of prostate tenderness. ASYMPTOMATIC PROSTATITIS
Urinalysis and urine culture testing may identify leukocytes Asymptomatic prostatitis is usually diagnosed incidentally
in the urine after prostate massage. Importantly, hematuria when inflammatory cells are identified on semen analysis or
and an elevated prostate-specific antigen level should not be prostate biopsy during evaluation for other entities. No specific
ascribed to chronic prostatitis/CPPS.27 Referral to urology for treatment or evaluation is necessary, and any further workup is

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 PROSTATITIS

directed by the primary urologic symptom.14,32 The condition’s 16. Ulleryd P, Sandberg T. Ciprofloxacin for 2 or 4 weeks in the treatment
prognostic value is unclear. of febrile urinary tract infection in men:​a randomized trial with a 1
year follow-up. Scand J Infect Dis. 2003;​35(1):​34-39.
17. Ha US, Kim ME, Kim CS, et al. Acute bacterial prostatitis in Korea:​
This article updates previous articles on this topic by Holt, clinical outcome, including symptoms, management, microbiology and
course of disease. Int J Antimicrob Agents. 2008;​31(suppl 1):​S96-S101.
et al.33 ; Coker and Dierfeldt13 ; Sharp, et al.5 ; and Stevermer
18. Lee DS, Choe HS, Kim HY, et al. Acute bacterial prostatitis and
and Easley.34
abscess formation. BMC Urol. 2016;​16(1):​38.
19. Schaeffer AJ. Prostatitis:​US perspective. Int J Antimicrob Agents.
Data Sources: A PubMed search was completed in Clinical Que-
1999;​11(3-4):​205-211, discussion 213-216.
ries using the key terms acute prostatitis and chronic prostatitis.
20. Schaeffer AJ. Clinical practice. Chronic prostatitis and the chronic
The search included meta-analyses, randomized controlled pelvic pain syndrome. N Engl J Med. 2006;​355(16):​1690-1698.
trials, clinical trials, observational studies, and reviews. The 21. Nickel JC, Shoskes D, Wang Y, et al. How does the pre-massage and
Agency for Healthcare Research and Quality Effective Health- post-massage 2-glass test compare to the Meares-Stamey 4-glass test
in men with chronic prostatitis/chronic pelvic pain syndrome? J Urol.
care Reports, the Cochrane database, DynaMed, and Essential
2006;​176(1):​119-124 .
Evidence Plus were also searched. Search date: May 11, 2024.
22. Perletti G, Marras E, Wagenlehner FME, et al. Antimicrobial therapy
for chronic bacterial prostatitis. Cochrane Database Syst Rev. 2013;​
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