Prostatitis

By Lori Lerner, MD, Boston University School of Medicine

Reviewed By Leonard G. Gomella, MD, Sidney Kimmel Medical College at Thomas Jefferson
University

Reviewed/Revised Feb 2025

Prostatitis refers to a disparate group of prostate disorders that manifests

with a combination of predominantly irritative or obstructive urinary
symptoms and perineal pain. Some cases result from bacterial infection of
the prostate gland and others, which are more common, from a poorly
understood combination of noninfectious inflammatory factors, spasm of
the muscles of the urogenital diaphragm, or both. Diagnosis is clinical,
along with microscopic examination and culture of urine samples obtained
before and after prostate massage. Treatment is with an antibiotic if the
cause is bacterial. Nonbacterial causes are treated with warm sitz baths,
muscle relaxants, anti-inflammatory medications, anxiolytics including
selective serotonin reuptake inhibitors (SSRIs), and pelvic floor physical
therapy.

Etiology of Prostatitis

Prostatitis can be bacterial or, more commonly, nonbacterial. However, differentiating bacterial
and nonbacterial causes can be difficult, particularly in chronic prostatitis.

Bacterial prostatitis can be acute or chronic and is usually caused by typical urinary
pathogens (eg, Klebsiella, Proteus, Escherichia coli) and possibly by Chlamydia. How these
pathogens enter and infect the prostate is unknown. Chronic infections may be caused by
sequestered bacteria that antibiotics have not eradicated, such as can happen in patients with
prostatic calcifications.

Nonbacterial prostatitis can be inflammatory or noninflammatory. The mechanism is unknown

but may involve incomplete relaxation of the urinary sphincter and dyssynergic voiding. The
resultant elevated urinary pressure may cause urine reflux into the prostate (triggering an
inflammatory response) or increased pelvic autonomic activity leading to chronic pain without
inflammation.
Classification of Prostatitis

Prostatitis is classified into 4 categories (see table NIH Consensus Classification System for
Prostatitis). These categories are differentiated by clinical findings and by the presence or
absence of signs of infection and inflammation in 2 urine samples. The first sample is a
midstream collection. Then digital prostate massage is done, and patients void immediately;
the first 10 mL of urine constitutes the second sample. Infection is defined by bacterial growth
in urine culture; inflammation is defined by the presence of white blood cells in urine. The use
of the term prostatodynia for prostatitis without inflammation is discouraged.

TABLE

NIH Consensus Classification System for Prostatitis

Characteri Urine Premassa Postmass

Number Category
stics Finding ge age

Acute
Acute WBC +/− +
symptoms
I bacterial
of urinary
prostatitis Bacteria +/− +
infection

Recurrent
WBC +/− +
Chronic urinary
II bacterial infection
prostatitis with same
Bacteria +/− +
organism

Chronic
prostatitis
III /chronic Primarily
pelvic pain symptoms
syndrome of pain,
Inflammator voiding, and WBC − +
IIIa sexual
y Bacteria − −
dysfunction
Noninflamm WBC − −
IIIb
atory* Bacteria − −

IV Asymptoma Discovered WBC − +

tic incidentally
inflammator during
y prostatitis urologic
 Characteri Urine Premassa Postmass
Number Category
stics Finding ge age

evaluation
(eg, prostate
biopsy,
seminal
fluid Bacteria − −
analysis) for
other
conditions
* Previously called prostatodynia.

+/− means possibly present; + means present; − means absent.

NIH = National Institutes of Health; WBC = white blood cell.

Data from Krieger JN, Nyberg L, Nickel JC: NIH consensus definition and classification of
prostatitis. JAMA 282:236–237, 1999.

Symptoms and Signs of Prostatitis

Symptoms vary by category but typically involve some degree of urinary irritation or
obstruction and pain. Irritation is manifested by frequency and urgency, a sensation of
incomplete bladder emptying, a need to void again shortly after voiding, or nocturia. Pain is
typically in the perineum but may be perceived at the tip of the penis, lower back, or testes.
Some patients report painful ejaculation.

Acute bacterial prostatitis often causes such systemic symptoms as fever, chills, malaise, and
myalgias. The prostate is exquisitely tender and focally or diffusely swollen, boggy, indurated,
or a combination. A generalized sepsis syndrome may result, characterized by tachycardia,
tachypnea, and sometimes hypotension.

Chronic bacterial prostatitis manifests with recurrent episodes of infection with or without
complete resolution between bouts. Symptoms and signs tend to be milder than in acute
prostatitis.

Chronic prostatitis/chronic pelvic pain syndrome typically has pain as the predominant
symptom, including pain with voiding and with ejaculation. The discomfort can be significant
and often markedly interferes with quality of life. Symptoms of urinary irritation or obstruction
also may be present. On examination, the prostate may be tender but usually is not boggy or
swollen. Clinically, inflammatory and noninflammatory types of chronic prostatitis/chronic
pelvic pain syndrome are similar.

Asymptomatic inflammatory prostatitis causes no symptoms and is discovered incidentally

during evaluation for other prostate diseases when white blood cells are present in the urine or
on histologic evaluation of prostate tissue after prostate biopsy or surgery.

Diagnosis of Prostatitis

Urinalysis

Prostate massage except possibly in acute bacterial prostatitis

Often a diagnosis of exclusion

Diagnosis of type I, II, or III prostatitis is suspected clinically. Similar symptoms can result from
urethritis, perirectal abscess, or urinary tract infection. Palpation of the prostate on digital
rectal examination is helpful diagnostically only in type 1 (acute bacterial prostatitis). However,
rectal examination in patients with types II, III, or IV may reveal increased rectal tone with an
inability to relax the anal sphincter. In these patients, pressure on the perineum may elicit
tenderness and pain.

Febrile patients with typical symptoms and signs of acute bacterial prostatitis usually have
white blood cells and bacteria in a midstream urine sample. Prostate massage to obtain a
postmassage urine sample is thought to be unnecessary and possibly dangerous in these
patients (although danger remains unproved) because bacteremia can be induced. For the
same reason, rectal examination should be done gently. Blood cultures should be obtained in
patients who have fever and severe weakness, confusion, disorientation, hypotension, or cool
extremities. For patients without these findings, urine samples before and after massage are
adequate for diagnosis.

For patients with acute or chronic bacterial prostatitis who do not respond favorably to
antibiotics, transrectal ultrasound, contrast-enhanced pelvic computed tomography (CT), and
sometimes cystoscopy may be necessary to exclude prostate abscess or destruction and
inflammation of the seminal vesicles.

For patients with types II, III, and IV (nonacute prostatitis) disease, additional tests that can be
considered are cystoscopy and urine cytology (if hematuria is also present) and urodynamic
measurements (if there is suspicion of neurologic abnormalities or detrusor-sphincter
dyssynergia).

Treatment of Prostatitis
 Treatment varies significantly with etiology

Acute bacterial prostatitis

Nontoxic patients can be treated at home with antibiotics, bed rest, analgesics, stool
softeners, and hydration. Therapy with a fluoroquinolone (eg, ciprofloxacin 500 mg orally twice
a day or ofloxacin 300 mg orally twice a day) is usually effective and can be given until culture
and sensitivity results are known. If the clinical response is satisfactory, treatment is
continued for about 30 days to prevent chronic bacterial prostatitis.

If bacteremia or sepsis is suspected, the patient is hospitalized and given broad-spectrum

antibiotics IV (eg, ampicillin plus gentamicin). Antibiotics are started after the appropriate
cultures are taken and continued until the bacterial sensitivity is known. If the clinical response
is adequate, IV therapy is continued until the patient is afebrile for 24 to 48 hours, followed by
oral therapy usually for 4 weeks.

Adjunctive therapies include nonsteroidal anti-inflammatory drugs and potentially alpha-

blockers (if bladder emptying is poor) and supportive measures such as sitz baths. Rarely,
prostate abscess develops, requiring surgical drainage.

Chronic bacterial prostatitis

Chronic bacterial prostatitis is treated with oral antibiotics such as fluoroquinolones for at
least 6 weeks. Therapy is guided by culture results; empiric antibiotic treatment for patients
with equivocal or negative culture results has a low success rate. Other treatments include
anti-inflammatory medications, muscle relaxants (eg, cyclobenzaprine to possibly relieve
spasm of the pelvic muscles), alpha-adrenergic blockers, medications to manage pain
(amitriptyline or gabapentin, SSRIs), and other symptomatic measures, such as pelvic floor
physical therapy or sitz baths.

Chronic prostatitis/chronic pelvic pain syndrome

Treatment is difficult and often unrewarding. Algorithms for treatment have been developed
(1) similar to those used for interstitial cystitis/bladder pain syndrome (2). In addition to
considering any and all of the above treatments, anxiolytics (eg, SSRIs, benzodiazepines),
sacral nerve stimulation, biofeedback, prostatic massage, acupuncture, pelvic floor physical
therapy, and minimally invasive prostatic procedures (such as microwave thermotherapy) have
been attempted with varying results. Many patients can achieve relief, but identifying an
effective treatment must be individualized and can take time and trial and error before finding
a suitable solution.

Asymptomatic inflammatory prostatitis

Asymptomatic prostatitis requires no treatment.
Treatment references
1. Clemens JQ, Mullins C, Ackerman AL, et al. Urologic chronic pelvic pain syndrome:
insights from the MAPP Research Network. Nat Rev Urol 2019;16(3):187-200.
doi:10.1038/s41585-018-0135-5
2. Clemens JQ, Erickson DR, Varela NP, Lai HH. Diagnosis and Treatment of Interstitial
Cystitis/Bladder Pain Syndrome. J Urol 2022;208(1):34-42.
doi:10.1097/JU.0000000000002756

Key Points

Prostatitis can be an acute or chronic bacterial infection or a more poorly

understood group of disorders typically characterized by irritative and
obstructive urinary symptoms, urogenital diaphragm muscle spasm, and
perineal pain.

Treat patients who have chronic bacterial prostatitis and nontoxic patients who
have acute bacterial prostatitis with a fluoroquinolone and symptomatic
measures.

Hospitalize patients who have acute bacterial prostatitis and systemic

symptoms that suggest sepsis and give broad-spectrum antibiotics such as
ampicillin plus gentamicin.

For men with chronic prostatitis or chronic pelvic pain syndrome, follow
algorithms for chronic pelvic pain, which include anxiolytics (eg, SSRIs,
benzodiazepines), sacral nerve stimulation, biofeedback, pelvic floor physical
therapy, pain management with gabapentin or amitriptyline, prostatic massage,
and minimally invasive prostatic procedures (eg, microwave thermotherapy).

Prostate Abscess Benign Prostatic Hyperplasia