Chronic Bacterial Prostatitis Clinical Presentation

Updated: May 18, 2023
  • Author: Samantha D Kraemer, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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Patients with chronic bacterial prostatitis (CBP) often present with history of recurrent urinary tract infections (UTIs). Presenting complaints may vary from patient to patient, and may include any of the following:

  • Dysuria
  • Urinary urgency and frequency
  • Urinary hesitancy or retention
  • Hematuria
  • Malodorous urine
  • Urethral discharge

Between episodes of acute infections, some patients are asymptomatic, while others may describe a long history of persistent symptoms similar to chronic prostatitis/pelvic pain syndrome (CPPS). Fevers and chills are uncommon, as they are typically seen only with acute bacterial prostatitis. 

A sexual history should also be taken. Specifically, the patient should be queried about multiple partners, unprotected anal intercourse, and the possibility of sexually transmitted diseases.

Patients with CBP and persistent symptoms similar to CPPS may present with a wide range of signs and symptoms. The four main domains of prostatitis symptoms include the following [27] :

  • Genitourinary pain
  • Lower urinary tract symptoms (LUTS)
  • Psychological issues
  • Sexual dysfunction​

Genitourinary pain will most commonly will be in the perineum (roughly 63%), testicles, suprapubic area, and penis (especially the penile tip), but can also include the groins, rectum, lower abdomen, or low back. Pain may also occur or increase during urination or ejaculation. Neuropathic pain can also contribute to symptoms.

LUTS may include obstructive storage symptoms or voiding symptoms. Obstructive storage urologic symptoms include the following:

  • Urinary frequency
  • Urgency or urge incontinence
  • Hesitancy
  • Dysuria
  • Nocturia
  • Postvoid dribbling

Voiding symptoms include the following:

  • Weak stream
  • Straining
  • Urinary hesitancy

Recurrent episodes of acute UTI with LUTS is typical for CBP. Patients who have these symptoms persistently are more likely to have CPPS. 

Psychological issues associated with prostatitis include the following:

  • Depression
  • Anxiety or stress
  • Overall decreased quality of life
  • Cognitive or behavioral deficits

Sexual dysfunction associated with prostatitis includes the following{ref14]:

  • Ejaculatory pain
  • Hematospermia
  • Erectile dysfunction
  • Decreased libido
  • Premature or delayed ejaculation

In patients with persistent symptoms, further evaluation should be done to assess their quality of life, functional status, and satisfaction with care. The National Institutes of Health's Chronic Prostatitis Collaborative Research Network developed a symptom index that is widely used for clinical evaluation and research. It has been accepted by the international prostatitis research community and shown to be reliable in primary care and clinical trials. [28, 29, 7]

The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) covers the three most important domains of chronic prostatitis with nine questions. The first domain, pain, is captured in four questions covering location, severity, and frequency. The second domain, urinary function, is captured in two questions covering irritative storage symptoms and obstructive voiding function. The third domain, quality of life, is captured in three questions covering how the symptoms effect daily activities. The NIH-CPSI is pictured below.

US National Institutes of Health chronic prostatit US National Institutes of Health chronic prostatitis symptom index.

Other validated symptom-scoring instruments that can be used to evaluate patients and monitor response to interventions include the International Prostate Symptoms Score (IPPS) and the Urinary, Psychosocial, Organ-specific, Infection, Neurological/systemic, Tenderness (UPOINT) classification. IPPS is an eight-item questionnaire that evaluates urinary symptoms and impact on quality of life. UPOINT classification helps to stratify patients into phenotypes based on their symptoms and has been used to phenotypically direct multimodal treatment in CPPS. [30]


Physical Examination

Physical examination is important and should be helpful in classifying the disorder, which guides therapy. Findings in CBP, similar to CPPS, may be normal except for localized tenderness and pain. 

Prostate examination by digital rectal examination (DRE) shoud be done after collection of preprostatic massage urine specimens. The prostate may be normal in size and consistency or may seem slightly boggy. Pain during prostate examination is variable and unhelpful for classifying the type of prostatitis. [1]  In contrast, acute bacterial prostatitis is characterized by a very tender, warm, swollen, boggy gland. When acute bacterial prostatitis is suspected, prostate massage should be avoided because of the risk of causing bacteremia.

Prostatic calculi are rarely palpable on prostate examination because they are typically located deep within the prostate gland. If calculi are palpable they are a significant clue to the cause of the recurrences, because they can be a nidus for infection.

Pelvic floor muscle dysfunction can also be evaluated by palpating the deep muscles duirng DRE and the perineum and superficial pelvic floor muscles externally. The strength and endurance of muscles, quality and timing of contractions, and ability to relax the muscles between contractions should be evaluated. 

An abdominal exam should also be done, to help exclude other causes of pain. A palpable bladder may be appreciated if the patient has urinary retention.