eMedicine Specialties > Emergency Medicine > Infectious Diseases

Prostatitis: Differential Diagnoses & Workup

Author: Tarlan Hedayati, MD, Instructor of Clinical Emergency Medicine, Director of Observation Unit, Director of Chest Pain Unit, Department of Emergency Medicine, Los Angeles County/University of Southern California Medical Center
Coauthor(s): Molly Keegan, MD, Resident Physician, Department of Emergency Medicine, Los Angeles County and USC Medical Center
Contributor Information and Disclosures

Updated: Jul 29, 2009

Differential Diagnoses

Anal Fistulas and Fissures
Prostate cancer
Back Pain, Mechanical
Radiculopathies
Benign prostatic hyperplasia
Testicular cancer
Chronic pain syndromes
Urethritis, Male
Cystitis
Urinary Incontinence
Erectile dysfunction
Urinary Obstruction
Foreign Bodies, Rectum
Urinary Tract Infection, Male
Hemorrhagic Cystitis: Noninfectious
Urolithiasis

Workup

Laboratory Studies

  • Complete blood count: A complete blood count (CBC) with differential and blood cultures are indicated in cases of acutely toxic patients or suspected septicemia.
  • Urinalysis: Obtain quantitative values for the white blood count and bacterial count, presence of oval fat bodies, and lipid-laden macrophages.
  • Urine culture: A urine culture can be used to identify the causative organism, if any.


Urine culture with greater than 100,000 colony-fo...

Urine culture with greater than 100,000 colony-forming units (CFU) of Escherichia coli, the most common pathogen in acute and chronic prostatitis. Chronic bacterial prostatitis must be confirmed and diagnosed using a urine culture.

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Urine culture with greater than 100,000 colony-fo...

Urine culture with greater than 100,000 colony-forming units (CFU) of Escherichia coli, the most common pathogen in acute and chronic prostatitis. Chronic bacterial prostatitis must be confirmed and diagnosed using a urine culture.

  • Chemistry: Obtain electrolyte panel, including BUN and creatinine values, in patients presenting with urinary retention or obstruction.
  • Prostate-specific antigen determination: Prostate inflammation can lead to elevation of serum prostate-specific antigen (PSA). PSA is used primarily as a cancer screening tool and should not be routinely used in the diagnosis of prostatitis.3

Imaging Studies

  • Trans-abdominal ultrasonography or bladder scan to assess for volume of retained urine.1
  • Transrectal ultrasonography
    • Characteristic features are capsular thickening and prostatic calculi.
    • Hypoechoic halo in the periurethral region, heterogeneous echo pattern, and enlargement and thickening of the septa of the seminal vesicles may be seen.
    • Interpretation is highly subjective and therefore not very reliable; diagnosis requires clinical correlation and digital rectal examination.
  • In acute prostatitis, a marked increase in color in the prostatic urethral site, around the ejaculatory ducts, and close to the seminal vesicles is visualized on color Doppler ultrasonography.
  • Computed tomography (CT) studies of the pelvis may be useful in evaluation of prostatic abscess or suspected neoplasm.
  • Cystoscopy is useful in follow-up of refractory cases to rule out neoplasm of the bladder or interstitial cystitis.
  • Intravenous urography or voiding cystourethrography is appropriate for evaluation of the outlet system in patients with full renal function.

Other Tests

  • Fractional urine examination
    • The use of fractional urine specimens may be useful in the diagnosis of prostatitis. Although not practical in most emergency departments, this technique is used by urologists if the diagnosis of prostatitis remains unclear.
    • The initial 10 mL of voided urine represents urine from the urethra and is termed voided urine 1 (V1). Elevated bacterial counts in V1 suggest urethritis. The next 200 mL of voided urine is discarded, and a midstream urine sample (V2) is collected, which represents bladder urine. Bacterial counts elevated in the midstream sample suggest cystitis without prostatitis. Next, the physician performs a prostatic massage and the expressed prostatic secretions (EPS) are collected from the urethral meatus. Finally, the 10 mL of voided urine following prostatic massage (V3) are collected. The bacterial findings of the EPS and V3 samples represent the microbiologic characteristics of the prostate gland.
    • Chronic bacterial prostatitis can be diagnosed if the culture of the EPS and V3 samples produce the same bacteria as the first-voided specimen and the colony count of the 2 cultures is at least 10 times as great as the first-void specimen.

Procedures

  • Suprapubic catheterization: This may be warranted in severe obstruction and should be placed in consultation with a urologist.
  • Needle biopsy or aspiration: In cases of prostatic abscess, the fluctuant site may be drained under local anesthesia through the perineal route, followed by insertion of a pigtail catheter.
  • Urodynamic testing may be indicated.
  • Cystoscopy may be performed to rule out bladder cancer and interstitial cystitis.

More on Prostatitis

Overview: Prostatitis
Differential Diagnoses & Workup: Prostatitis
Treatment & Medication: Prostatitis
Follow-up: Prostatitis
Multimedia: Prostatitis
References
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Further Reading

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Keywords

prostatitis, acute bacterial prostatitis, chronic bacterial prostatitis, nonbacterial prostatitis, prostatodynia, prostate gland, bacterial prostatitis, chronic pelvic pain syndrome, CPPS, asymptomatic inflammatory prostatitis, prostatic inflammation

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Contributor Information and Disclosures

Author

Tarlan Hedayati, MD, Instructor of Clinical Emergency Medicine, Director of Observation Unit, Director of Chest Pain Unit, Department of Emergency Medicine, Los Angeles County/University of Southern California Medical Center
Tarlan Hedayati, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Molly Keegan, MD, Resident Physician, Department of Emergency Medicine, Los Angeles County and USC Medical Center
Disclosure: Nothing to disclose.

Medical Editor

David S Howes, MD, Residency Program Director, Professor of Medicine, Section of Emergency Medicine, University of Chicago/Pritzker School of Medicine
David S Howes, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eddy Lang, MDCM, CCFP (EM), CSPQ, Assistant Professor, Department of Family Medicine, McGill University; Consulting Staff, Department of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Eddy Lang, MDCM, CCFP (EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH, Professor and Chair, Department of Emergency Medicine, University of Virginia Health System
Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

 
 
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