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Sexual Health

Prostatitis

Prostatitis ranges from acute bacterial infection with systemic illness and urinary symptoms to chronic bacterial prostatitis and chronic pelvic pain syndrome; the first priorities are to recognise sepsis or retention, obtain cultures without delaying treatment, and avoid confusing non-bacterial pain with an infection that needs antibiotics.

In a nutshell

Prostatitis is not one disease. Acute bacterial prostatitis is a potentially serious systemic urinary infection causing fever, perineal or pelvic pain and lower urinary tract symptoms; obtain cultures, treat promptly and look for sepsis, retention and abscess. Chronic bacterial prostatitis requires microbiological confirmation and specialist treatment. Chronic pelvic pain syndrome is managed multimodally and should not receive repeated empirical antibiotics.

Classic presentation

A person with a prostate has abrupt fever, malaise, perineal pain and dysuria with a tender prostate on gentle examination; ask about urinary retention and sepsis immediately.

Key points

  • Acute bacterial prostatitis usually comes from urinary pathogens, but STI testing is needed when the history or urethral symptoms support it.
  • Do a gentle digital rectal examination if useful, but never massage the prostate in acute infection.
  • Take a midstream urine culture and treat promptly; avoid delaying therapy in systemic illness.
  • NICE antibiotics require a 14-day review, and failure or worsening raises concern for abscess, resistance, obstruction or another diagnosis.
  • Fluoroquinolones require the MHRA safety restriction and BNF/local-policy check; do not use them for non-bacterial chronic pelvic pain syndrome.
  • Symptoms lasting at least 3 months need separation of chronic bacterial prostatitis from chronic pelvic pain syndrome.

First-line investigation

Severity and sepsis assessment, gentle examination, midstream urine dipstick and culture, blood cultures and blood tests when systemically unwell, plus targeted STI testing when indicated.

Management

Treat acute bacterial prostatitis as a potentially systemic infection

  • Assess sepsis and urinary retention, obtain cultures without delaying treatment, avoid prostate massage and involve hospital teams when the patient is unstable or cannot take oral therapy.3,1

Choose antibiotics with culture, safety and prostate penetration in mind

  • Use the current NICE acute-prostatitis pathway and local resistance data, review at 14 days, and apply MHRA and BNF restrictions to any fluoroquinolone prescription.3,6,5

Drain retention and search for abscess when response is poor

  • Urgent urology is needed for retention, persistent fever or non-response; use imaging selectively for abscess or obstruction and drain an abscess when required.1,2

Test and treat STI-related disease through sexual health

  • Use first-void NAAT and appropriate sexual-health testing when STI risk is present, then follow current BASHH treatment and partner-management pathways.1,4

Separate chronic bacterial disease from pelvic pain syndrome

  • For symptoms lasting at least 3 months, use specialist microbiology to distinguish chronic bacterial prostatitis from chronic pelvic pain syndrome and avoid repeated antibiotics without evidence of infection.1,2,6

Exam traps

  • Never massage an acutely inflamed prostate: it can precipitate bacteraemia and sepsis.
  • A negative dipstick or culture after antibiotics does not make severe acute disease safe to ignore.
  • PSA may be raised in prostatitis and is not a diagnostic test during active inflammation.
  • Retention, persistent fever or treatment failure should prompt urology review and abscess or obstruction assessment.
  • Do not use fluoroquinolones for non-bacterial chronic pelvic pain syndrome.
  • Do not label all chronic pelvic or perineal pain as chronic bacterial prostatitis without microbiological support.

Illustrations

Chronic prostatitis on histologyH&E prostate histology showing a dense chronic inflammatory infiltrate surrounding prostatic glands, the pathological correlate of chronic prostatitis.Nephron, Wikimedia Commons · CC-BY-SA-3.0

Key sources

  1. EAU Guidelines on Urological Infections, limited update 2026 (Current specialist guideline on bacterial prostatitis classification, gentle examination, cultures, localisation testing, imaging, abscess, antimicrobial treatment and follow-up)
  2. NHS, Prostatitis (Current NHS information on symptoms, urgent retention or non-response advice, antibiotic treatment and chronic prostatitis support)
  3. NICE NG110, Prostatitis (acute): antimicrobial prescribing (Current NICE acute prostatitis antimicrobial recommendations, including oral first-line choices, 14-day review, intravenous review at 48 hours, self-care and MHRA fluoroquinolone safety links)Published 31 Oct 2018
  4. BASHH, National guideline for the management of infection with Neisseria gonorrhoeae (Current UK gonorrhoea guideline used to route confirmed or suspected gonococcal disease to the specialist sexual-health treatment pathway)Published 1 Apr 2025
  5. BNF, current antimicrobial prescribing information (Current UK prescribing cross-check for antimicrobial selection, renal dosing, interactions, contraindications, safety counselling and monitoring; detailed BNF access is restricted in this environment)
  6. MHRA, Fluoroquinolone antibiotics: restrictions and precautions (Current UK safety restriction requiring systemic fluoroquinolones to be used only when other commonly recommended antibiotics are inappropriate, with warnings about disabling and potentially long-lasting or irreversible adverse effects)Published 22 Jan 2024

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.