History & Examination

Symptoms characteristic of acute prostatitis include:

• a feverish illness of sudden onset
• irritative urinary voiding symptoms (dysuria, frequency, urgency) or acute urinary retention
• perineal or suprapubic pain (low back pain, pain on ejaculation, and pain during bowel movements can also occur)

Examination

• A focused physical examination is important so that abnormalities of the abdomen and external genitalia are not missed and left untreated
• Urine dipstick test suggesting that there are white blood cells and bacteria in the urine

Signs of Acute prostatitis include:

• Signs localised to the prostate:
  • An extremely tender, swollen and tense, smooth-textured prostate gland which is warm to the touch
  • Digital rectal exam (DRE) may not be possible because of extreme discomfort

Signs of the bacteraemia:

• Patients with Acute Prostatitis are usually systemically unwell
  • Pyrexia and tachycardia

Differential Diagnoses

Acute Prostatitis is uncommon.

• Consider Acute Prostatitis as an STI in younger adults
• Does the patient have symptoms of UTI with signs of prostatism? (see UTI in males pathway)
• Chronic Pelvic Pain Syndrome / Chronic Prostatitis:
  • Apyrexial, no systemic signs
  • The patient may have a diffusely tender prostate during acute episodes otherwise no objective clinical signs (see Chronic Pelvic Pain Syndrome)

Red Flag/Urgently refer patients if:

• A suspicion of prostate or bladder cancer see 2WW referral
• Storage symptoms in a heavy smoker
• Chronic retention which may present as night time enuresis / over flow incontinence and/ or painless palpable bladder needs renal function checking and refer urgently

• Consider Prostate-Specific Antigen (PSA) as a baseline

Management in primary care

Formulary Chapter 5: Urinary Tract Infections

Reassess after 24-48 hours - review the culture results and ensure that an appropriate antibiotic is being used.

Adequate response to treatment

If sure of diagnosis:

• Refer all men when they have recovered. Investigation of the urinary tract is required to exclude structural abnormality

Inadequate response to treatment - after appropriate antibiotic treatment:

• Refer to Urology
• Discuss with microbiologist
• Complications such as prostatic abscess should be assessed for, and this may require transrectal ultrasound (TRUS) examination or CT scan of the prostate
• If present, perineal or transurethral drainage may be necessary

Referral criteria

Admit to hospital if the patient:

• is unable to take oral antibiotics − parenteral therapy should be arranged
• is severely ill
• shows symptoms of acute urinary retention − suprapubic catheterisation is required (inserting a urethral catheter may spread the infection through the blood)
• has deteriorating symptoms despite appropriate antibiotic treatment

Refer to Urology urgently:

• if the patient has pre-existing urological conditions (such as benign prostatic hypertrophy or an indwelling catheter) specialist urological management may be required
• any patient who is immunocompromised or has diabetes
• if the infection is not responding adequately to treatment

Refer to Urology routinely:

• all men when they have recovered. Investigation of the urinary tract is required to exclude structural abnormality

Referral instructions

Referral to Urology:

e-Referrals service selection

• Specialty: Urology
• Clinic Type: Not otherwise specified
• Service: DRSS-Northern – Urology – NHS Devon ICB – 99p

Referral form

DRSS Referral Form

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: June 2020