Prostatitis

Objectives

To guide the management of patients presenting with acute prostatitis.

There is a separate guideline here for insertion of urinary catheters.

Definitive treatment (surgical) is covered in specialist guidance.

Scope

This guideline describes the management of patients with prostatitis in military settings, from forward emergency care through stabilisation to ward-based care.

Audience

This guideline is intended for registered healthcare professionals working in a general role within a forward medical location, resuscitation facility, or emergency department during deployed operations.

Initial Assessment & Management

Acute bacterial prostatitis is a severe, potentially life-threatening infection of the prostate, often accompanied by a urinary tract infection.

Suspect acute prostatitis in all male patients presenting with:

·       Sudden onset perineal, lower back, or suprapubic pain

·       Dysuria, urinary frequency, or urgency

·       Difficulty initiating urination or urinary retention

·       Fever, chills, malaise

·       Delirium or confusion (particularly in elderly patients)

·       Erectile or ejaculatory pain

Alternative differential diagnosis should also be considered:

Benign prostatic hyperplasia (BPH): gradual reduction in urinary flow, hesitancy, nocturia, or acute urinary retention.

Chronic prostatitis: symptoms persisting for several weeks or months.

Urinary tract infection.

Epididymo-orchitis: unilateral or bilateral scrotal, testicular, or epididymal pain/swelling, usually with dysuria and urinary frequency.

Prostate malignancy: usually painless; may cause acute retention. On digital rectal examination, prostate feels enlarged, hard, irregular, and non-tender. PSA is often elevated although this test is not normally available in the deployed setting.

Examination:

Vital signs: check standard signs for pyrexia, tachycardia, hypotension, or other signs of sepsis. If identified, following guidance on managing the septic patient here.

Abdominal exam should assess for suprapubic tenderness or bladder distension

Digital rectal exam is likely to identify a tender, swollen, or “boggy” prostate
 

Investigations:

Midstream urine: dipstick (forward care), culture and sensitivity (if available in deployed hospital care) 

Blood tests: U&Es, FBC, CRP, ESR (as available in deployed hospital care)

STI screening (e.g., Chlamydia, Gonorrhoea), particularly in high-risk patients
 
 

Management:

Antibiotics should be initiated empirically in accordance with the current DMS antimicrobial policy.

Always consider previous culture/sensitivity results, antibiotic history, tolerance, and resistance risk

Analgesia: paracetamol, NSAIDs

Fluids: maintain adequate hydration

Anti-emetics: as required

Monitor for urinary retention — if present, insert catheter if trained personnel and equipment are available. Catheterisation may be challenging. Suprapubic catheterisation may be required, seek surgical advice. See separate CGO for procedural details. 

Prolonged Casualty Care

• Patients should be advised that uncomplicated prostatitis may last several weeks.
• For chronic or refractory cases, consider extending antibiotic treatment up to 28 days.
• If available review antibiotic choice based on sensitivity results, aiming for a narrow-spectrum agent where possible.
• If STI is identified, follow specific guidance or seek GUM advice.
• If symptoms worsen, do not improve within 48 hours, or patient becomes systemically unwell, switch to intravenous antibiotics.

Paediatric Considerations

Acute bacterial prostatitis is rare in children. When it occurs, it is often associated with UTIs, bacteraemia, or trauma. The possibility of sexual abuse should be considered in all paediatric cases.