Case Study of the Week: Acute Bacterial Prostatitis

This week's case study is a shout-out to all the guys out there.  Happy Prostate Cancer Awareness Month.  While I'm sure there are a few things you'd rather think about on this lovely Tuesday afternoon than the prostate, this little organ can cause some big problems for men.  Understanding diseases of the prostate is of utmost importance as an NP or PA, so take some time to explore the diagnosis and management of prostatitis.

Accounting for nearly 2 million outpatient visits per year, prostatitis is a prevalent problem.  Prostatitis is divided into four categories: acute bacterial prostatitis, chronic bacterial prostatitis, chronic prostatitis with chronic pelvic pain syndrome and asymptomatic inflammatory prostatitis.  Nurse practitioners and physician assistants must be able to diagnose and treat these conditions as more than eight percent of males can expect to experience at least one type of prostatitis in their lifetime.

Case Presentation

A 50 year-old patient presents to your clinic complaining of fever, chills and bodyaches especially in the low back along with painful urination and urinary frequency.  The patient reports no prior similar symptoms.  He has a medical history including hypertension and type 2 diabetes, both of which are well controlled on medications.  The patient's vital signs are as follows: Pulse 104, Temperature 100.2, Blood pressure 132/88.  

On exam you note suprapubic abdominal tenderness and a distended bladder.  The patient's prostate is tender and enlarged.  Suspecting prostatitis, you oder a urine sample which comes back positive for leukocytes, bacteria and white blood cells.  Labs show a mildly elevated white blood cell count.  BUN and creatinine are normal.  You send the urine sample for culture to direct antibiotic therapy if necessary.  Based on this patient's symptoms, exam and lab findings, you diagnose him with acute bacterial prostatitis. 

Management and Outcome

Patients that are well-appearing with acute bacterial prostatitis may be treated on an outpatient basis with antibiotics.  In younger men, especially under the age of 35, sexually transmitted infection may be the cause of bacterial prostatitis and these individuals should be given antibiotics effective against chlamydia and gonorrhea including IM ceftriaxone and oral azithromycin or doxycycline.  

For other patients where STI's are not suspected, quinolones or trimethoprim-sulfamethoxazole are the antibiotics of choice.  Patients should be treated with a 14 to 28 day course of antibiotics.  Urine culture will show the pathogen responsible for causing prostatitis and antibiotic therapy should be tailored to the urine culture results once they are received.

Extremely ill patients may require hospitalization for IV antibiotics and supportive therapy.  In patients not responding to antibiotic therapy, the possibility of a prostate abscess should be considered.  A prostate abscess may be detected on digital exam or with CT or ultrasound.  

Discussion

Acute bacterial prostatitis must be treated promptly and appropriately as aggressive treatment decreases the chance of developing chronic prostatitis.  Checking PSA levels during an episode of acute prostatitis is not recommended, however if PSA (Prostate Specific Antigen) levels are checked, they may be elevated.  PSA levels should return to normal within one to three months.  Patients whose PSA level remains elevated should have close follow-up and an evaluation for prostate cancer if indicated.  

While acute bacterial prostatitis typically resolves with a few weeks of antibiotic therapy, complications of this condition such as prostate abscess, sepsis and predisposition to chronic prostatitis can occur.  

 

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Comments

What about patient teaching? Nursing should have a greater focus on prevention and patient education to keep these things from happening in the first place, rather than the failed symptomatic model of the medical model. Great case study nevertheless!

Oz