Prostatitis

7.08 Prostatitis

Presentation
A man complains of fever, chills, perineal or low back pain, and may have urinary urgency and frequency, as well as signs of obstruction to urinary flow ranging from a weak stream to urinary retention. On gentle examination, the prostate is swollen and tender. The infection may spread from or into, the contiguous urogenital tract (epididymis, bladder, urethra), or the bloodstream.
What to do:



Perform a rectal examination and only once, gently palpate the prostate to see if it is tender, swollen, or edematous.



Culture the urine to help identify the organism responsible (although there is no guarantee that the bacteria in the prostate will be in the urine).



For patients 35 years and younger, treat for gonorrhea and other urethritis with ceftriaxone (Rocephin) 125mg im to1000mg iv and azithromycin (Zithromax) 1000mg po.



For men over 35 years old, begin empirical treatment with ciprofloxacin 400mg iv, then 500mg po bid.



Arrange for urological followup.
What not to do:



Do not massage, or repeatedly palpate the prostate. Rough treatment is unlikely to help drain the infection or produce the responsible organism in the urine, but is likely to extend or worsen a bacterial prostatitis, or precipitate bacteremia or septic shock.
Discussion
Not only is it difficult to obtain the organism responsible for prostatitis; it is difficult to identify an antibiotic with the correct spectrum which will also enter the prostate. Trimethoprim/sulfamethoxazole and doxycycline are alternatives.
 Blood in the ejaculate may be a sign of inflammation in the prostate and epididymis or, especially in younger males, may simply be a self-limiting sequela of vigorous sexual activity.