0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:19
1226 Prostatitis■Rectal exam reveals tender, swollen, and indurated prostate.
■Urinary retention revealed by bladder percussion
Chronic Prostatitis
■History and physical much more subtle
■May present as vague perineal or back pain with low-grade fever
■Digital exam reveals boggy enlarged prostate, without extraordinary
tenderness.tests
■Urine and blood cultures – suspectEscherichia coli,Enterococcus sp.,
Klebsiella sp.,Enterobacter sp.,Serratia sp.,Proteus sp.,Morganella
sp., andProvidencia sp., in outpatient setting;Pseudomonas sp.in
hospitalized patient
■In patients <35, considerN. gonorrheaandC. trachomatis(rare).
■Pre- and post-prostatic massage cultures of urine are only neces-
sary/helpful for chronic prostatitis.
■Prostatic-specific antigen will be nonspecifically elevated.
■Transrectal ultrasound necessary to rule out prostatic abscess in
cases refractory to treatment
differential diagnosis
■Prostatic hypertrophy, prostadynia, prostate cancer, prostatic
abscess, proctitis, cystitis, pyelonephritis
management
■Hydration
■Relief of urinary obstruction (catheter)
specific therapy
■Treat empirically with quinolone or trimethoprim-sulfamethoxa-
zole for at least 14 days for acute prostatitis.
■Some would argue for 28 days of treatment to prevent chronic pro-
statitis, prostatic abscess.
■Chronic prostatitis can require treatment courses of 6 weeks to
6 months.
■Due to increasing resistance in both inpatient and outpatient set-
tings, treatment must be modified based on culture and sensitivity
results. Do not assume that empiric choice is correct.
follow-up
■Expect rapid (within 24 h) improvement for treatment of acute pro-
statitis.
■If improvement not rapid, consider complications (see below).