Prostatitis, a major source of chronic infection and symptoms in men, occurs rarely in prepubertal children. Although prostatitis may develop in postpubertal teenagers, even in this age group the diagnosis is recognized infrequently. The disorder commonly termed prostatitis generally is divided into four separate clinical problems based on the National Institutes of Health Classification of prostatitis: acute bacterial prostatitis, chronic bacterial prostatitis, chronic prostatitis and chronic pelvic pain syndrome, and asymptomatic inflammatory prostatitis. This chapter will focus on acute or chronic bacterial prostatitis.

Acute prostatitis is a severe infection generally associated with significant toxicity (high fever, systemic symptoms such as malaise, chills, nausea, and vomiting). Marked urinary symptoms, such as frequency, suprapubic pain, dysuria, hematuria, and urinary retention, may be present. On rectal examination, the prostate is enlarged, boggy (edematous), and exquisitely tender. The urine usually is infected. Care must be taken when performing the rectal examination or when inserting a transurethral catheter because bacteremia can result. The white blood cell count and inflammatory markers are usually elevated. Urinalysis is abnormal, and urine culture is positive in the majority of cases. Bacteremia has been reported in up to 20% of patients, and blood cultures may be positive when urine cultures are negative.

The organism responsible usually is one of the gram-negative pathogens that commonly causes urinary tract infection (UTI). Escherichia coli is most commonly isolated, but other pathogens include Proteus mirabilis , Pseudomonas aeruginosa , and Klebsiella and Enterococcus spp., among others. Neisseria gonorrhoeae is a consideration in sexually active males. Community-associated methicillin-susceptible as well as methicillin-resistant Staphylococcus aureus isolates have been isolated rarely from patients with a prostatic abscess.

The virulence factors of E. coli strains recovered from men with acute prostatitis and women with UTIs, such as adhesins and cytotoxins, were similar in one study. Johnson and colleagues found, however, that prostatitis E. coli isolates differed significantly from E. coli associated with cystitis or pyelonephritis by having a higher prevalence of the genes encoding P fimbriae structural subunits, P fimbriae assembly, fimbriae tip pilins, hemolysin, and cytotoxic necrotizing factor, and a lower prevalence of the gene encoding invasion of brain endothelium virulence factor. In a study of E. coli isolates from 18 previously healthy young men with acute bacterial prostatitis, Krieger and colleagues reported that most isolates fell within the family of considered extraintestinal pathogenic E. coli (ExPEC) and carried a median of 12.5 virulence genes, characteristic of ExPEC gene clusters. Rarely Trichomonas vaginalis can cause prostatitis.

If the patient is not systemically ill, in adults a quinolone such as ciprofloxacin or levofloxacin or trimethoprim-sulfamethoxazole is generally recommended because these agents have been more carefully studied for this indication than oral cephalosporins. These same agents also are reasonable for male adolescents. Modification of antibiotic therapy is based on the organism isolated and its antibiotic susceptibilities. The duration of treatment is generally 14 to 28 days. If the patient is more seriously ill, parenteral therapy is recommended. Empiric treatment generally begins with administration of broad-spectrum β-lactam agents, such as cefotaxime or piperacillin-tazobactam possibly combined with an aminoglycoside, that are effective against gram-negative enteric organisms pending the availability of culture-proven sensitivity results and a satisfactory clinical response. Once the patient has clearly improved and is stable, therapy can be completed with an oral agent such as a fluoroquinolone or trimethoprim-sulfamethoxazole based on susceptibility results.

Patients with suspected acute bacterial prostatitis who are receiving appropriate antibiotics but are not improving should undergo further evaluation. Ultrasound may reveal evidence of abscess formation. Computed tomography or magnetic resonance imaging may provide more detailed information on the size and location of a prostate abscess. Drainage by an interventional radiology procedure or transurethral unroofing may be required to adequately treat a prostatic abscess.

Chronic bacterial prostatitis is a more indolent infection associated with intermittent UTI, bladder irritative symptoms, and perineal discomfort. Recurrent urethritis or epididymitis may be present. Ejaculation may be painful. Expressed prostatic secretions usually show an increase in the white blood cell count. Common organisms associated with chronic bacterial prostatitis are similar to those causing acute bacterial prostatitis, including Klebsiella spp., E. coli , P. mirabilis , P. aeruginosa , and Enterococcus faecalis . E. coli isolates associated with chronic prostatitis possess urovirulence profiles similar to those of strains from women with acute uncomplicated pyelonephritis.

The diagnosis of chronic bacterial prostatitis is related partly to detecting inflammation in expressed prostatic secretions. More precise methods of determining inflammatory parameters, such as counting the white blood cells per cubic millimeter with a hemocytometer, have been proposed. In a large cohort study, the severity of symptoms in men with chronic prostatitis did not correlate with leukocyte or bacterial counts, however.

Chronic bacterial prostatitis accounts for only a small fraction of men with chronic prostatitis syndromes. The cause of nonbacterial chronic prostatitis and chronic pelvic pain syndrome remains enigmatic. Prostatic secretions do not show a common organism consistently, and UTI does not recur. Culture of prostatic secretions is notoriously unreliable because of the means by which this material is collected; these secretions are contaminated easily as they pass through the urethra. A specific causal relationship in nonbacterial prostatitis has not been found for either Ureaplasma urealyticum or Chlamydia trachomatis, two organisms commonly implicated in urethritis. Molecular studies using polymerase chain reaction have shown DNA evidence of the presence of bacteria despite negative cultures for the typical bacteria associated with prostatitis. Using these new techniques may lead to greater understanding of the role of infection in the pathogenesis of prostatitis.

Treatment of chronic bacterial prostatitis is frustrating because few patients truly are cured, and relapse occurs commonly after discontinuation of antibiotic therapy. Several studies have confirmed satisfactory concentrations of most common antibiotics in prostatic tissues, but no study has provided a convincing explanation for the high treatment failure rate. Levofloxacin and other fluoroquinolones penetrate well into seminal and prostatic fluids and reach concentrations equivalent to corresponding plasma levels. Researchers have postulated that antibiotic concentrations may be inadequate within the acini of the prostatic glands and their secretions, but this theory has not been proved. Typically, fluoroquinolones for 4 to 6 weeks of administration are the agents of choice for treating chronic bacterial prostatitis.

In the older age group still seen in a pediatric practice, symptoms similar to those of the chronic form of prostatitis also might occur with urethritis. As noted earlier, Chlamydia and Ureaplasma spp. commonly are found in the urethral discharge in these patients and are thought to be responsible for these specific symptoms. These organisms also have been implicated as a cause of epididymitis in young men. The organisms are transmitted sexually and are treated effectively with a tetracycline (minocycline or doxycycline) or a macrolide (erythromycin or azithromycin). To prescribe these drugs empirically for sexually active young adults with lower tract irritative symptoms and clinical findings consistent with urethritis while awaiting culture results seems reasonable.