Overview

Prostatitis refers to a spectrum of conditions involving inflammation of the prostate gland, ranging from acute bacterial infection to chronic pelvic pain syndromes. It is a common urological condition affecting men of all ages, particularly those aged 30–50 years. The National Institutes of Health (NIH) classifies prostatitis into four categories: acute bacterial, chronic bacterial, chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), and asymptomatic inflammatory prostatitis. Acute bacterial prostatitis is usually caused by gram-negative organisms such as E. coli, while CP/CPPS is the most common subtype and is often non-infectious.

Anatomy & Physiology 

• Prostate gland: Located below bladder, surrounds urethra
• Function: Produces prostatic fluid contributing to semen
• Zones: Peripheral, central, transition zones
• Drainage: Via prostatic ducts into urethra

Aetiology & Risk Factors

Aetiology

• Bacterial infection (E. coli, gram-negative organisms)
• Non-infectious inflammation
• Pelvic floor dysfunction

Risk Factors

• Urinary tract infections
• Catheterisation
• Recent urological procedures
• Sexual activity
• Bladder outlet obstruction

Pathophysiology

Acute bacterial prostatitis

• Ascending infection from urethra or reflux of infected urine into prostatic ducts
• Common organisms: E. coli and other gram-negative bacteria
• Acute inflammation → oedema, glandular swelling → urinary obstruction and pain
• Systemic spread → fever, bacteraemia, sepsis

Chronic bacterial prostatitis

• Persistent bacterial colonisation within prostatic ducts
• Biofilm formation → poor antibiotic penetration
• Recurrent infection → chronic inflammation and fibrosis

Chronic pelvic pain syndrome (CP/CPPS)

• No clear infection
• Neurogenic inflammation → sensitisation of pelvic nerves
• Pelvic floor muscle dysfunction → pain and urinary symptoms
• Psychological factors may contribute (stress, central sensitisation)

Asymptomatic inflammatory prostatitis

• Subclinical inflammation
• Often incidental finding on biopsy or semen analysis

Clinical Manifestations

Acute bacterial prostatitis

• Fever, chills, malaise (systemic features)
• Dysuria, frequency, urgency
• Acute urinary retention
• Perineal, suprapubic, or low back pain
• Painful ejaculation
• Tender, boggy prostate on DRE

Chronic bacterial prostatitis

• Recurrent urinary tract infections
• Dysuria, frequency, urgency (milder than acute)
• Perineal or pelvic discomfort
• Pain with ejaculation
• Usually no systemic symptoms

Chronic pelvic pain syndrome (CP/CPPS)

• Chronic pelvic/perineal pain (>3 months)
• Pain with ejaculation
• Urinary symptoms (frequency, urgency, hesitancy)
• Sexual dysfunction
• No identifiable infection
• Exam often normal or mild tenderness

Asymptomatic inflammatory prostatitis

• No symptoms
• Incidental finding on biopsy or semen analysis

Diagnosis

Investigations

• Urinalysis and culture
• Prostate exam (avoid in acute severe cases)
• PSA (may be elevated)
• Imaging if abscess suspected

Classification

Treatment

• Acute bacterial: antibiotics (fluoroquinolones, TMP-SMX)
• Chronic bacterial: prolonged antibiotics
• CP/CPPS: alpha-blockers, NSAIDs, pelvic therapy
• Supportive care (hydration, pain control)

Complications and Prognosis

Complications

• Prostatic abscess
• Sepsis
• Chronic pelvic pain
• Urinary retention

Prognosis

• Acute: good with treatment
• Chronic: relapsing course
• CP/CPPS: long-term management required

References

1. Krieger JN, et al. NIH classification of prostatitis.
2. Rees J, et al. Prostatitis guidelines. Eur Urol. 2015.
3. NICE Guidelines. Prostatitis.