A man complains of fever, chills, perineal or low back
pain, and may have urinary urgency and frequency, as well as
signs of obstruction to urinary flow ranging from a weak
stream to urinary retention. On gentle examination, the
prostate is swollen and tender. The infection may spread
from or into, the contiguous urogenital tract (epididymis,
bladder, urethra), or the bloodstream.
What to do:
Perform a rectal examination and only once, gently palpate
the prostate to see if it is tender, swollen, or
edematous.
Culture the urine to help identify the organism
responsible (although there is no guarantee that the
bacteria in the prostate will be in the urine).
For patients 35 years and younger, treat for gonorrhea and other urethritis with ceftriaxone (Rocephin) 125mg im to1000mg iv and azithromycin (Zithromax) 1000mg po.
For men over 35 years old, begin empirical treatment with ciprofloxacin 400mg iv, then 500mg po bid.
Arrange for urological followup.
What not to do:
Do not massage, or repeatedly palpate the prostate. Rough
treatment is unlikely to help drain the infection or
produce the responsible organism in the urine, but is
likely to extend or worsen a bacterial prostatitis, or
precipitate bacteremia or septic shock.
Discussion
Not only is it difficult to obtain the organism responsible
for prostatitis; it is difficult to identify an antibiotic
with the correct spectrum which will also enter the
prostate. Trimethoprim/sulfamethoxazole and doxycycline are
alternatives.
Blood in the ejaculate may be a sign of inflammation in the
prostate and epididymis or, especially in younger males, may
simply be a self-limiting sequela of vigorous sexual
activity.
