Prostatitis, Bacterial



Chronic bacterial prostatitis represents an infection of the prostate gland. By definition, this condition is characterized by bacterial growth in culture of the expressed prostatic fluid, semen, or postmassage urine specimen. The expressed prostatic secretion (EPS) usually contains more than 10 white blood cells (WBCs) per high-power field (HPF) and macrophages.

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Bacterial prostatitis. Expressed prostatic fluid contains more than 10 white blood cells per high-power field, indicating prostatitis.

The hallmark of chronic bacterial prostatitis is the occurrence of relapsing urinary tract infections, usually involving the same pathogen. Chronic bacterial prostatitis is often confused with nonbacterial prostatitis, chronic pelvic pain syndrome (CPPS), and prostatodynia.


The prostate gland is an accessory sex gland, providing approximately 15% of the ejaculate. The base of the prostate abuts the bladder neck, while the apex is in continuity with the membranous urethra, resting on the urogenital diaphragm.

The adult prostate weighs approximately 20 g but may grow dramatically with age (see Prostate Hyperplasia, Benign). The approximate dimensions are 4.4 cm transversely at the base, 3.4 cm in length, and 2.6 cm in anteroposterior diameter. Antibacterial factors within the prostate, such as zinc, help to prevent infection.



United States

Prostatitis accounts for approximately 2 million annual visits. Twenty-five percent of all men evaluated for urologic problems in the United States are estimated to have symptoms of prostatitis. Approximately 50% of men experience symptoms of prostatitis at some time in their life. However, less than 5-10% of men with symptoms of prostatitis have bacterial prostatitis. Evaluation for these symptoms makes up approximately 8% of all urology visits.


Worldwide, 8 million prostatitis-related visits are reported annually.



No racial predilections have been identified.


Bacterial prostatitis affects in males.


Chronic bacterial prostatitis typically affects men aged 40-70 years. Benign prostatic hyperplasia typically affects the same age group.


Relapsing urinary tract infections, interspersed with asymptomatic periods, are common in persons with chronic bacterial prostatitis. Although some men are diagnosed because of asymptomatic bacteriuria, most have varying degrees of irritative voiding symptoms, such as dysuria, frequency, and urgency.

In addition, some patients report feelings of a vague discomfort in the pelvis and perineum. Fevers and chills are uncommon. Rectal palpation of the prostate is not painful and produces no specific findings. Prostatic fluid and postmassage urine cultures, which should be obtained for precise diagnosis, demonstrate bacterial growth.


The physical examination findings, including the findings on prostate examination via digital rectal examination, are typically normal.


The actual routes of prostatic infection are unknown in most cases, but various etiologies may be found. Ascending urethral infection is a known route because of the frequency of previous gonococcal prostatitis, as well as the finding of identical organisms in prostatic fluid and vaginal culture in many couples. Intraprostatic urinary reflux has been demonstrated in human cadavers and may play a role.

Laboratory Studies

The various prostatitis syndromes have been classified based on EPS and culture findings. This classification system is important for therapy because the various categories are treated differently. The presence of 10 or more WBCs/HPF in the EPS is considered clinically significant inflammation.

Imaging Studies

Other Tests

Histologic Findings

Prostate biopsy is not used to diagnose chronic bacterial prostatitis. However, prostate biopsy samples collected to evaluate prostate cancer may demonstrate focal areas of inflammation characterized by a lymphocytic response. The pathology report is often described as chronic prostatitis.

Although this type of finding may suggest chronic bacterial prostatitis, it also may represent nonbacterial prostatitis. The history of chronic urinary tract infections provides the clinical diagnosis.

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A nonspecific mixed inflammatory infiltrate that consists of lymphocytes, plasma cells, and histiocytes is typical in chronic bacterial prostatitis.

Medical Care

The mainstay in the treatment of chronic bacterial prostatitis is the use of oral antimicrobial agents. The most effective medications are fluoroquinolones and TMP-SMZ.

All other oral agents are unlikely to eradicate the pathogenic bacteria successfully within the prostate because of suboptimal tissue penetration. Longer courses of antibiotic use provide better treatment outcomes. Relapse is not uncommon.

Surgical Care

Prostatectomy is rarely indicated in the treatment of chronic bacterial prostatitis. When used, radical transurethral prostatectomy is suggested. This procedure may be more effective in men with prostatic calculi. Because most of the inflammation is located in the peripheral zone of the gland, an extensive resection of the gland is required to remove all infected and potentially infected tissue down to the level of the true prostatic capsule.

Only one series of 10 patients, most with prostatic calculi, has been reported, but all men were considered cured.[9] This procedure is indicated, although only rarely, in men with well-documented bacterial infections in whom medical pharmacotherapy fails for one year.

For refractory cases, other authorities have suggested that transurethral microwave therapy to ablate prostate tissue has shown some benefit.[10] At this time, this intervention should be considered only in patients who have failed less-invasive therapies yet do not desire radical transurethral prostatectomy. Larger series would be helpful to define the benefit of this procedure.

Intraprostatic injection of antimicrobial agents is suggested to obtain high concentrations of antimicrobial agents in the prostatic parenchyma. Plomp et al (1980) noted a 66% bacteriologic cure rate with thiamphenicol in 29 men.[11] Jiminez-Cruz et al (1988) noted a 59% cure rate with aminoglycoside injection in 51 men.[12] Unfortunately, these studies have significant methodological flaws, so the conclusions cannot be considered definitive. This technique is rarely used.


Consultation with a urologist may be appropriate for men with relapsing chronic bacterial prostatitis or when the diagnosis is unclear. A urologist may be able to properly perform the bacterial localization studies necessary to diagnose chronic bacterial prostatitis. In the author's experience, most primary care physicians are not comfortable or experienced with obtaining VB1, VB2, EPS, and VB3 specimens. Semen cultures or urine cultures collected before and following prostatic massage are simpler and represent effective alternatives to the 3-cup test.


Diet does not have an important role in treating chronic bacterial prostatitis. Some physicians have advocated the avoidance of spicy and caffeine-containing foods; however, no evidence has indicated any benefit in chronic bacterial prostatitis.


Medication Summary

The goals of pharmacotherapy are to treat the infection and to reduce morbidity.

Ciprofloxacin (Cipro)

Clinical Context:  Bactericidal antibiotic that inhibits bacterial DNA synthesis, and consequently growth, by inhibiting DNA-gyrase in susceptible organisms.

Ofloxacin (Floxin)

Clinical Context:  Penetrates the prostate well and is effective against Neisseria gonorrhea and C trachomatis.

Levofloxacin (Levaquin)

Clinical Context:  Indicated for pseudomonal infections and those that are due to multidrug-resistant gram-negative organisms.

Trimethoprim-sulfamethoxazole (TMP-SMZ, Bactrim)

Clinical Context:  Inhibits bacterial synthesis of dihydrofolic acid by competing with para -aminobenzoic acid. This results in the inhibition of bacterial growth.

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Fluoroquinolones are frequently used because they are able to concentrate in the prostate and are lipid soluble. Sulfonamides are also used because they are lipid-soluble.

Further Outpatient Care


A recent retrospective study has suggested a relationship between the severity of chronic prostatitis symptoms and erectile dysfunction frequency. Whether this relationship is mediated through organic or psychologic mechanisms remains unclear, and further studies to investigate this relationship would be helpful.[13]



Joe D Mobley III, MD, MPH, Chief Resident Physician, Department of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine/University of Tennessee Medical Center

Disclosure: Nothing to disclose.


Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

Specialty Editors

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Shlomo Raz, MD, Professor, Department of Surgery, Division of Urology, University of California at Los Angeles School of Medicine

Disclosure: Nothing to disclose.

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan

Disclosure: Terumo Corporation Consulting fee Consulting; Gyrus-ACMI Honoraria Speaking and teaching

Chief Editor

Bradley Fields Schwartz, DO, FACS, Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Disclosure: Nothing to disclose.


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Bacterial prostatitis. Expressed prostatic fluid contains more than 10 white blood cells per high-power field, indicating prostatitis.

Urine culture with greater than 100,000 colony-forming units (CFU) of Escherichia coli, the most common pathogen in acute and chronic prostatitis. Chronic bacterial prostatitis must be confirmed and diagnosed using a urine culture.

A nonspecific mixed inflammatory infiltrate that consists of lymphocytes, plasma cells, and histiocytes is typical in chronic bacterial prostatitis.

Bacterial prostatitis. Expressed prostatic fluid contains more than 10 white blood cells per high-power field, indicating prostatitis.

A nonspecific mixed inflammatory infiltrate that consists of lymphocytes, plasma cells, and histiocytes is typical in chronic bacterial prostatitis.

Urine culture with greater than 100,000 colony-forming units (CFU) of Escherichia coli, the most common pathogen in acute and chronic prostatitis. Chronic bacterial prostatitis must be confirmed and diagnosed using a urine culture.