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Acute Bacterial Prostatitis Workup

  • Author: Samuel G Deem, DO; Chief Editor: Edward David Kim, MD, FACS  more...
Updated: Dec 09, 2015

Approach Considerations

In patients with acute bacterial prostatitis (ABP), prostatic secretions contain large numbers of leukocytes and fat-laden macrophages. However, prostatic massage to obtain secretions should not be performed as it is rarely necessary for diagnosis.

Because prostatitis may cause irritative and obstructive voiding symptoms that mimic other primary causes of those symptoms, the use of urodynamics may possibly be helpful to avoid misdiagnosis of prostatitis. However, this is more the situation in chronic prostatitis; in acute prostatitis, this should not be necessary.

The presence of a prostatic abscess is confirmed with transrectal ultrasonography and noncontrast computed tomography (CT) scanning of the pelvis.

Occasionally, blood culture results are positive.


Urine Studies

A urinalysis that shows leukocytes and a positive result on urine culture are essential for the diagnosis of acute bacterial prostatitis (ABP). To confirm the prostate as the site of involvement, the tests can be conducted on paired urine specimens collected before and after massage of the prostate; this is known as the two-glass test.[10]

If the patient is febrile or exhibits signs of acute bacterial prostatitis, only the midstream urine is collected for urine culture. The prostatic massage is contraindicated.

Urethral swab culture and postmassage urine culture as well as microscopic examination may be an alternative standard protocol to simplify the evaluation of prostatitislike syndrome in clinical practice.[11]

The evaluation for chronic prostatitis may include first-voided urine, midstream urine, urine after prostatic massage, and expressed prostatic secretions to localize the nidus of infection, as described by Meares and Stamey.[12]


Serum PSA Levels

Serum prostate-specific antigen (PSA) levels are also increased in prostatitis but should not be used as a screening test for this condition. In the setting of acute bacterial prostatitis (ABP), PSA has little to no clinical value. If the PSA level is obtained and is found to be elevated, the study should be repeated 30-60 days after adequate treatment. Studies have shown that a 2- to 4-week treatment with antibiotics decreased the PSA levels in approximately half of patients with PSA levels in the gray zone who did not have prostatitis symptoms.[13]


CT Scanning/Transrectal Ultrasonography

Imaging studies, including computed tomography (CT) scanning of the pelvis or transrectal ultrasonography, should be reserved for cases in which findings from laboratory analyses are equivocal or when no improvement is observed following medical therapy.

Ruling out complications of prostatitis (eg, prostatic abscess) is a strong indication to proceed to imaging studies. Transrectal ultrasonography and CT scanning of the pelvis can be very useful in diagnosing and draining prostatic abscesses.[14] However, transrectal ultrasonography should be performed as gently as possible to prevent bacteremia.


Biopsy and Histology

Histologically, the normal prostate gland is composed of tubuloalveolar glands. The glandular spaces are lined by epithelium, which is composed of 2 layers of cells—a basal layer of low cuboidal epithelium covered by a layer of columnar mucus-secreting cells. The glands have a distinct basement membrane and are separated by a fibromuscular stroma.

Prostate biopsy is contraindicated in patients with suspected acute bacterial prostatitis (ABP) because of the potential complication of seeding the bacterial infection in adjacent organs and the risk of gram-negative sepsis. Furthermore, prostate biopsy is extremely painful without a prostatic nerve block. The current practice is to anesthetize the area before core biopsy sampling.

In prostatitis, a stromal leukocytic infiltrate may be accompanied by increased prostatic secretion or leukocytic infiltration within gland spaces (see image below). When complicated by abscess formation, focal or larger areas of the prostate become necrotic.

Leukocytic infiltration of the stroma and glandulaLeukocytic infiltration of the stroma and glandular lumina during acute bacterial prostatitis (ABP).
Contributor Information and Disclosures

Samuel G Deem, DO Faculty, Department of Urology, Charleston Area Medical Center

Samuel G Deem, DO is a member of the following medical societies: American College of Surgeons, American Osteopathic Association, American Urological Association, Endourological Society, Society of Urologic Oncology, American Society of Clinical Oncology, American College of Osteopathic Surgeons

Disclosure: Nothing to disclose.


Michael Piesman, MD Staff Physician, Department of Internal Medicine, Madigan Army Medical Center

Michael Piesman, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Raymond A Costabile, MD Jay Y Gillenwater Professor of Urology and Vice Chairman, Senior Associate Dean for Clinical Strategy, University of Virginia Health System

Raymond A Costabile, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society of Andrology, American Urological Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Jonathan J Rhee, MD Physician, MidAtlantic Urology Associates

Jonathan J Rhee, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

Chief Editor

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

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.


Edmund S Sabanegh Jr, MD Chairman, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation

Edmund S Sabanegh Jr, MD is a member of the following medical societies: American Medical Association, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Society for the Study of Male Reproduction, Society of Reproductive Surgeons, and Southwest Oncology Group

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Leukocytic infiltration of the stroma and glandular lumina during acute bacterial prostatitis (ABP).
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