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State-of-the-Art Review: Diagnosis and Management of Acute and Chronic Bacterial Prostatitis - Beyond the Abstract

Bacterial prostatitis remains a clinically challenging and often underrecognized infectious syndrome with substantial diagnostic and therapeutic uncertainty. In this review, we critically evaluated the current medical literature to highlight clinically relevant insights into the diagnosis and management of bacterial prostatitis while also examining the major limitations, controversies, and knowledge gaps that continue to hinder evidence-based care.1

Unfortunately, for the practicing clinician, these gaps in knowledge are wide, and evidence related to many important clinical questions is limited. Despite the release of NIH consensus definitions of prostatitis nearly three decades ago, few clinical trials have addressed topics such as the presenting symptoms and signs of prostatitis, empiric choices for antibiotic therapy, or duration of treatment.2 Much of the literature references prior review articles, which in turn reference older review articles or small retrospective studies.3,4 For example, human immunodeficiency virus (HIV) infection is often mentioned as a risk factor for the development of prostatic abscess. However, cited evidence is limited to a 1980s retrospective cohort and small case series from the 1990s, a time period before the modern antiretroviral therapy era.5,6

Additionally, the lack of standardization for diagnosing acute bacterial prostatitis (ABP) is evident in the heterogeneous inclusion criteria used in studies of ABP. Criteria range from vague definitions such as patients with a “physician-assigned diagnosis of acute prostatitis” to highly specific criteria, such as “1) one or more recent symptoms and signs such as voiding disturbance, dysuria, urgency, frequency, perineal pain, suprapubic pain or tenderness during digital rectal exam, 2) fever (37.8°C or higher), and 3) ≥5 white blood cells (WBC)/hpf in urine.”7,8 Other studies report a different cutoff for fever, no specified cutoff for WBC/hpf, or a completely different list of symptoms and signs. As clinical researchers, we are striving to standardize diagnostic criteria to help guide the approach used by frontline clinicians who treat this condition.

To further illustrate the problem that we encountered in assessing the quality of the limited evidence available about bacterial prostatitis, in our review article, we provided the example of the typical canonical advice to avoid digital rectal examination (DRE) in patients with suspected prostatitis. We noted that numerous articles recommended avoidance of DRE without clear citation of the evidence to support this statement. Those articles that did provide citations for this claim often referenced prior review articles and expert opinion. This claim seems to have originated from articles written in the 1970s (and earlier) by renowned experts in the prostatitis field that specifically advise against prostatic massage, which is not equivalent to DRE.9 Indeed, many articles actually describe finding a tender prostate on physical examination in ABP as a key diagnostic feature, an implicit endorsement of this maneuver to help with establishing a diagnosis. The key distinction is that a brief, gentle DRE to ascertain prostatic tenderness is different from vigorous prostatic massage of the prostate for at least 60 seconds. In our review of the published literature, we believe this distinction might have been lost over time and has led to continued teaching about universally avoiding any type of DRE in patients with ABP.

Even the number of men who develop ABP and/or chronic bacterial prostatitis (CBP) is uncertain, as the most relevant US data comes from the “Urologic Disease in America Project,” published in 2005, using data collected prior to the year 2000.10 Also, comparative trials exploring different treatment approaches for prostatitis are scarce. For ABP, this could be due in part to the previously described diagnostic challenges and lack of standardized diagnostic criteria. For CBP, trials comparing therapeutic options are limited almost exclusively to comparisons between different fluoroquinolones and a few comparing fluoroquinolones to other classes of antibiotics such as macrolides and tetracyclines. Notably, these trials have typically not included trimethoprim-sulfamethoxazole, one of the most commonly recommended and prescribed antibiotics for CBP, as well as other antibiotics prescribed for UTIs in general (e.g., cephalosporins or fosfomycin). The paucity of trials regarding therapeutic options for CBP is particularly important from a clinical perspective, as many CBP infections are likely attributable to Enterococcus, a pathogen that is typically resistant to fluoroquinolones.1

Bacterial prostatitis remains a fascinating subject and one that is highly relevant to the people who develop this condition. The existing literature raises more questions than answers. We hope that our literature summary will be of value, particularly in clarifying what we do not know, to inspire further research into areas of clinical need for bacterial prostatitis.

Written by:

  • Prathit A. Kulkarni, Medical Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Infectious Diseases Section, Department of Medicine, Baylor College of Medicine, Houston, Texas
  • Barbara W. Trautner, Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, MO; VA St. Louis Health Care System, St. Louis, MO
  • Tyler J. Brehm, Infectious Diseases Section, Department of Medicine, Baylor College of Medicine, Houston, TX; Center for Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
References:

  1. Kulkarni PA, Cortés-Penfield NW, Brehm TJ, et al. State-of-the-Art Review: Diagnosis and Management of Acute and Chronic Bacterial Prostatitis. Clin Infect Dis. Published online 2026. 
  2. Krieger JN, Nyberg L, Nickel JC. NIH consensus definition and classification of prostatitis. JAMA. 1999;282(3):236-237.
  3. Ackerman AL, Parameshwar PS, Anger JT. Diagnosis and treatment of patients with prostatic abscess in the post-antibiotic era. Int J Urol Off J Jpn Urol Assoc. 2018;25(2):103-110.
  4. Lee LK, Dinneen MD, Ahmad S. The urologist and the patient infected with human immunodeficiency virus or with acquired immunodeficiency syndrome. BJU Int. 2001;88(6):500-510.
  5. Trauzzi SJ, Kay CJ, Kaufman DG, Lowe FC. Management of prostatic abscess in patients with human immunodeficiency syndrome. Urology. 1994;43(5):629-633.
  6. Leport C, Rousseau F, Perronne C, Salmon D, Joerg A, Vilde JL. Bacterial prostatitis in patients infected with the human immunodeficiency virus. J Urol. 1989;141(2):334-336. doi:10.1016/s0022-5347(17)40759-2
  7. Lee DS, Choe HS, Kim HY, et al. Acute bacterial prostatitis and abscess formation. BMC Urol. 2016;16(1):38.
  8. Etienne M, Chavanet P, Sibert L, et al. Acute bacterial prostatitis: heterogeneity in diagnostic criteria and management. Retrospective multicentric analysis of 371 patients diagnosed with acute prostatitis. BMC Infect Dis. 2008;8:12.
  9. Meares EM. Prostatitis. Annu Rev Med. 1979;30:279-288. doi:10.1146/annurev.me.30.020179.001431
  10. Litwin MS, Saigal CS, Yano EM, et al. Urologic diseases in America Project: analytical methods and principal findings. J Urol. 2005;173(3):933-937.
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