🔬 Men's Health

Prostatitis — Prostate Infection vs BPH Guide

Understanding prostate pain and infection — distinct from BPH and prostate cancer

Prostatitis is inflammation of the prostate gland — a group of conditions affecting men of all ages, from young adults to the elderly. It is one of the most common urological diagnoses in men under 50 and accounts for approximately 8% of all urology visits. Despite its prevalence, prostatitis is often confused with BPH (benign prostatic hyperplasia — an enlarged prostate in older men) or prostate cancer. The four categories of prostatitis have distinct presentations and require different treatment approaches. In Nigeria, prostatitis is frequently misdiagnosed as a sexually transmitted infection, leading to prolonged unnecessary antibiotic courses and ongoing suffering.

Signs and Symptoms

✓ Acute bacterial prostatitis (most dramatic): high fever, chills, severe perineal/lower abdominal pain, inability to urinate (acute retention), dysuria, extremely tender prostate on examination

✓ Chronic bacterial prostatitis: recurrent UTIs in a man, perineal pain, lower back pain, testicular or penile pain, post-ejaculatory pain, urinary symptoms

✓ Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS — most common): pelvic pain in the perineum, lower abdomen, testicles, or penis for > 3 months. Urinary symptoms. Erectile dysfunction. NOT necessarily caused by bacteria

✓ Asymptomatic inflammatory prostatitis: found incidentally — no treatment needed

Risk Factors

Acute bacterial prostatitis: urethral catheterisation, cystoscopy, TRUS biopsy, STIs (gonorrhoea, chlamydia), urethral stricture, anal intercourse (E. coli from bowel)
Chronic bacterial prostatitis: poorly treated acute prostatitis, intraprostatic ductal reflux of urine
CP/CPPS: anxiety, depression, prior pelvic trauma, cycling, difficult anatomical voiding, pudendal nerve irritation. Often no identifiable cause
High-risk sexual behaviour (for STI-associated acute prostatitis)
Immunosuppression (HIV, diabetes, steroids)

When to Seek Help

High fever + difficulty urinating + severe perineal painAcute bacterial prostatitis — medical emergency. Sepsis can develop rapidly. IV antibiotics and often catheterisation needed

Acute urinary retentionAny urinary retention in a man with fever or pelvic pain — emergency catheterisation

Pelvic pain lasting > 3 monthsCP/CPPS — multidisciplinary assessment including urology, physiotherapy, and psychology

Recurrent UTIs in a manAlmost always indicates underlying structural or prostatic pathology — investigation essential

STI symptoms + urinary symptomsGonorrhoea and chlamydia can cause prostatitis — STI testing and specific treatment needed

Tests & Diagnosis

🧪 Urine dipstick and MSU culture

Positive leucocytes + nitrites in acute prostatitis. Culture identifies causative organism and antibiotic sensitivity

🧪 Urethral swab for STI (NAAT)

Chlamydia and gonorrhoea NAAT — especially in sexually active men under 40

🧪 PSA (prostate-specific antigen)

Often dramatically elevated in acute prostatitis (PSA may reach 100+ ng/mL). NOT used for prostate cancer diagnosis in acute prostatitis — repeat after 3 months recovery

🧪 Expressed prostatic secretions (EPS) — the Meares-Stamey 4-glass test

Gold standard for localising bacterial prostatitis — cultures from initial urine, mid-stream urine, post-massage urine, and prostatic secretions. Rarely performed in Nigerian hospitals but diagnostic

🧪 Pelvic and prostate ultrasound (TRUS)

Prostate abscess — a complication of acute prostatitis. Shows hypoechoic (dark) fluid collection. Emergency drainage needed

🧪 Full blood count and CRP

Leucocytosis and elevated inflammatory markers in acute bacterial prostatitis

Treatment Options

Acute bacterial prostatitis

IV antibiotics in hospital: ceftriaxone 1g daily or ciprofloxacin 400mg BD. Transition to oral ciprofloxacin 500mg BD or levofloxacin 500mg daily for 4–6 weeks total (fluoroquinolones penetrate the prostate well). Urinary catheter if retention. Analgesia and adequate hydration

Chronic bacterial prostatitis

Fluoroquinolone antibiotics for 4–6 weeks (the prostate is poorly penetrated by most antibiotics — longer courses needed). If STI-associated: doxycycline + ceftriaxone. Treat any underlying structural cause

CP/CPPS — multimodal treatment

Alpha-blockers (tamsulosin 0.4mg daily) — reduce urethral resistance and symptoms in many patients. NSAIDs for pain. Antibiotics (one 6-week trial of ciprofloxacin/doxycycline even without proven bacterial cause). Pelvic floor physiotherapy (myofascial trigger point release). Psychological support for chronic pain

Prostate abscess

Transrectal or transperineal drainage — often under ultrasound guidance. Prolonged IV antibiotics

Lifestyle measures for CP/CPPS

Reduce caffeine and alcohol (bladder irritants). Avoid prolonged cycling (perineal pressure). Warm baths (sitz baths) for perineal pain. Stress management

Frequently Asked Questions

Is prostatitis an STI?

Sometimes — but not always. Acute prostatitis in young men is sometimes caused by STIs (gonorrhoea, chlamydia) and warrants STI testing. However, CP/CPPS (the most common form) is not caused by STIs in most cases. PSA elevation from prostatitis does not mean you have been sexually promiscuous — this is a medically important distinction that affects treatment decisions and relationships.

How is prostatitis different from BPH?

BPH (benign prostatic hyperplasia) is enlargement of the prostate gland causing bladder outlet obstruction — primarily a disease of men over 50, causing slow stream, frequency, and incomplete emptying. Prostatitis is inflammation (with or without infection) causing pain — it affects men of all ages, including young men. They can coexist in older men. Treatment is completely different.

Will prostatitis cause prostate cancer?

No. Prostatitis does not cause prostate cancer. However, prostatitis (especially acute) dramatically raises PSA — causing concern about cancer. PSA should not be tested during active prostatitis. If PSA is elevated, repeat it at least 3 months after resolution of prostatitis before any further cancer investigation.

Why is CP/CPPS so difficult to treat?

CP/CPPS is a complex syndrome — for most men, no bacteria are found and the cause is unclear. Contributing factors may include pelvic floor muscle tension, pudendal nerve irritation, central pain sensitisation, psychological factors, and voiding dysfunction. Effective treatment requires addressing multiple factors simultaneously — not just antibiotics. Most men improve significantly with a multimodal approach, though complete cure is not always achieved.